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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What is pronator drift
RBC count >6000
90% of right handed and 60% of left handed persons; speech and language function
Pt is asked to hold both arms fully extended at shoulder level in front of him with palms upwards; unable to maintain such position means positive test; closing eye will accentuate the effect
Upright supine position

2. How to tx lewy body dementia
In BET - no resting tremor (tremor worsens at rest and improves with acitivity) - bradykinesia or slowing in voluntary movement; gait difficulty; have positive family hx
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cholinesterase inhibitor; and antiparkinsonism drugs
<20; if patient scores >25 benign forgetfulness

3. Tx of bells palsy
Aphasia - neglect - agnosia - acalculia etc
Tunnel vision - diaphoresis - nausea - pallor
Corticosteroid and acyclovir
Taper gradually to prevent seizure relapse

4. oligoclonal band in CSF
MS
82% specific for dementia
Both slowly progressive; huntington with abrupt jerk of limb - trunk - grimacing - other abnormal movement - picks are irritable - quiet - sucks lip frequently and have symmetric atrophy of frontal/temporal lobes
Taper gradually to prevent seizure relapse

5. dementia plus urinary incontinence
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

6. prodrome of vasovagal syncope
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
IVIG and plasmapheresis

7. excessive elevation of legs during walking (toe touch floor earlier than heels)
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

8. get up and go test
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Get up from chair walk a short distance turn around and sit; screening test for fall
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in writing - calculating - distinguishing left and write

9. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
<20; if patient scores >25 benign forgetfulness
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

10. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Taper gradually to prevent seizure relapse
Cerebellar lesion
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Diabetes insipidus

11. What mmse score suggest dementia
Reduced efficacy of OCP
Myasthenia; due to autoantibodies against acetylecholine receptor;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
<20; if patient scores >25 benign forgetfulness

12. differentiate wenicke and korsakoff
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Both in alcoholic; wernicke develop at first with horizontal nystagmus - and ataxia; if not treated they develop memory loss and psychosis which is named korsakoff
Entacapone - COMT inhibitor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

13. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Botulism has descending paralysis in contrast othere have ascending paralysis

14. How to stop antiepileptic drugs
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Taper gradually to prevent seizure relapse
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

15. MMSE score of less than 24
Entacapone - COMT inhibitor
Deficit in cranial nerve function
82% specific for dementia
Aphasia - neglect - agnosia - acalculia etc

16. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cholinesterase inhibitor; and antiparkinsonism drugs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS

17. How to tx acute exacerbation of MS
90% of right handed and 60% of left handed persons; speech and language function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
High dose IV methyleprednisone;

18. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Femoral n lesion

19. botulism
Cluster; l for lacrimation - you for unilateral; episodes occur in cluster/grops; each last 30 min to 3h; c for conjunctival injection; r for retroorbital pain/rhinorhoea
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Antitoxin
Distal lower motor neuron disease

20. When to suspect traumatic LP
EPV - campylobacter - HSV
RBC count >6000
Spastic paraparesis
Normal pressure hydrocephalus

21. How to differentiate parkinson and benign essential tremor
In BET - no resting tremor (tremor worsens at rest and improves with acitivity) - bradykinesia or slowing in voluntary movement; gait difficulty; have positive family hx
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebral palsy; dx mri
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

22. impaired hepatic conjugation of billirubin
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

23. brain stem lesion
Deficit in cranial nerve function
Femoral n lesion
First nerulogical exam must demonstrate absent cerebral and brainstem reflexes; absent motor response to pain - absent pupillary reflex - corneal reflex - cough reflex - and tracheal suctioning; then apnea test.
Propranolol or primidone

24. phenytoin and OCP
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Deficit in cranial nerve function
Reduced efficacy of OCP
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

25. infections in GBS
Nystagmus on far lateral gaze
Verapamil
EPV - campylobacter - HSV
Cerebellar lesion

26. Tx of GBS
Deficit in cranial nerve function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

27. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

28. How to tx stroke patient came after 6h
Taper gradually to prevent seizure relapse
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Aspirin - control HTN and swallow eval before giving any oral meds

29. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

30. How to differentiate medial and lateral pontine syndrome
EPV - campylobacter - HSV
Reduced efficacy of OCP
Lateral involve trigeminal which has L and has limb ataxia ; medial - ipsilateral limb ataxia and contralateral eye deviation and paralysis of face - arm and leg
Botulism has descending paralysis in contrast othere have ascending paralysis

31. craniopharyngioma
IVIG and plasmapheresis
Diabetes insipidus
EPV - campylobacter - HSV
Lesion in nondominant temporal lobe

32. How to differentiate medial and lateral medullary syndrome
MP: paralysis always medial due to involvement of f gracilis and f cunetus - so loss of touch and position sense and injury to hypglossal n in same side; lateral involve spinothalamic which has L; so pain and temp sensation altered;
Clonidine will take care both high bp and withdrawal
Wernicke's encephalopathy; due to thiamine definition; medical emergency
82% specific for dementia

33. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Reduced efficacy of OCP
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
L for l ; lewy has lots of hallucination; parkinsonism like features - falls are common; presence lewy body in cytosplasm of brain cells; vascular demential develop very suddenly; hx dm -htn - athero

34. differentiate picks and huntington
Myasthenia; due to autoantibodies against acetylecholine receptor;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Botulism has descending paralysis in contrast othere have ascending paralysis
Both slowly progressive; huntington with abrupt jerk of limb - trunk - grimacing - other abnormal movement - picks are irritable - quiet - sucks lip frequently and have symmetric atrophy of frontal/temporal lobes

35. severe headache and high BP
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

36. How to perform apnea test
Aphasia - neglect - agnosia - acalculia etc
20%
Propranolol or primidone
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

37. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting

38. When to use dopamine agonist pramipexol in parkinson
Difficulty in writing - calculating - distinguishing left and write
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
First nerulogical exam must demonstrate absent cerebral and brainstem reflexes; absent motor response to pain - absent pupillary reflex - corneal reflex - cough reflex - and tracheal suctioning; then apnea test.

39. When to use brain spect scintigraphy to confirm brain death
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
It patient has electrolyte imbalance and hypothermia
Verapamil

40. indication of plasmapheresis in GBS
Tunnel vision - diaphoresis - nausea - pallor
EPV - campylobacter - HSV
Deficit in cranial nerve function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

41. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cluster; l for lacrimation - you for unilateral; episodes occur in cluster/grops; each last 30 min to 3h; c for conjunctival injection; r for retroorbital pain/rhinorhoea
Antitoxin
Deficit in cranial nerve function
Cerebral palsy; dx mri

42. what drug is used to extend effects of levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Entacapone - COMT inhibitor
High dose IV methyleprednisone;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

43. women with unilateral eye pain; neurlogic symptoms here there at different times
90% of right handed and 60% of left handed persons; speech and language function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MP: paralysis always medial due to involvement of f gracilis and f cunetus - so loss of touch and position sense and injury to hypglossal n in same side; lateral involve spinothalamic which has L; so pain and temp sensation altered;

44. GBS
IVIG and plasmapheresis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Difficulty in writing - calculating - distinguishing left and write

45. best diagnosis for parkinsonim
High dose IV methyleprednisone;
Autospy gold standard
Entacapone - COMT inhibitor
In BET - no resting tremor (tremor worsens at rest and improves with acitivity) - bradykinesia or slowing in voluntary movement; gait difficulty; have positive family hx

46. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
In BET - no resting tremor (tremor worsens at rest and improves with acitivity) - bradykinesia or slowing in voluntary movement; gait difficulty; have positive family hx
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

47. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Obturator n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
If develop fever - mouth ulcer - easy brusing - petechie - see a doc ; the drug cause neutropenia - and bone marrow suppression; elderly are at risk of SIADH
Taper gradually to prevent seizure relapse

48. Should we tx htn in acute ischemic stroke

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49. cluster headache
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cluster; l for lacrimation - you for unilateral; episodes occur in cluster/grops; each last 30 min to 3h; c for conjunctival injection; r for retroorbital pain/rhinorhoea
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
82% specific for dementia

50. Patient with carbamazepine; What should be advice?
Entacapone - COMT inhibitor
L for l ; lewy has lots of hallucination; parkinsonism like features - falls are common; presence lewy body in cytosplasm of brain cells; vascular demential develop very suddenly; hx dm -htn - athero
High dose IV methyleprednisone;
If develop fever - mouth ulcer - easy brusing - petechie - see a doc ; the drug cause neutropenia - and bone marrow suppression; elderly are at risk of SIADH

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USMLE Step3 Neurology

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