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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

Instructions:

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 percent of dementia is reversible
Nystagmus on far lateral gaze
Cerebral palsy; dx mri
Construction apraxia; lesion in non dominant parietal lobe (right)
20%

2. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

3. best diagnosis for parkinsonim
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
Spastic paraparesis
Despite the term neuroma they arise from schwann cells - schwanoma
Autospy gold standard

4. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Antitoxin
Verapamil
RBC count >6000

5. What is can be used cluster headache prevention
Verapamil
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
Acetylecholinersterase inhibitors
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

6. women with unilateral eye pain; neurlogic symptoms here there at different times
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Antitoxin
Not within 24 hours; give afte 24-48 hours if patient stable
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

7. Tx of GBS
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
Deficit in cranial nerve function
Cerebral palsy; dx mri

8. alcoholic p/w confusion - ataxia - tremor - nystamgus

9. korsafoff psychosis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aphasia - neglect - agnosia - acalculia etc
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

10. MG
Clonidine will take care both high bp and withdrawal
Aspirin - control HTN and swallow eval before giving any oral meds
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Acetylecholinersterase inhibitors

11. GBS
Lesion in nondominant temporal lobe
Antitoxin
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
IVIG and plasmapheresis

12. indication of plasmapheresis in GBS
EPV - campylobacter - HSV
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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;

13. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
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
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

14. Tx of bells palsy
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Corticosteroid and acyclovir
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting

15. craniopharyngioma
Coronary artery disease
Cerebral palsy; dx mri
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Diabetes insipidus

16. When to give aspirin when patient on tPA after stroke
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
90% of right handed and 60% of left handed persons; speech and language function

17. When to start fibrinolytic therapy in stroke patient?
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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.
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

18. differentiate picks and huntington
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
MS
Aphasia - neglect - agnosia - acalculia etc

19. get up and go test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Coronary artery disease
EPV - campylobacter - HSV
Get up from chair walk a short distance turn around and sit; screening test for fall

20. When to use brain spect scintigraphy to confirm brain death
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Botulism has descending paralysis in contrast othere have ascending paralysis
It patient has electrolyte imbalance and hypothermia

21. infections in GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Vitamin B12 deficiency
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
EPV - campylobacter - HSV

22. stroke with lower facial palsy - pronator drift despite on aspirin
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in writing - calculating - distinguishing left and write
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

23. impaired perception of complex sounds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
<20; if patient scores >25 benign forgetfulness

24. lesion in dominant parietal lobe
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Lesion in nondominant temporal lobe
Difficulty in writing - calculating - distinguishing left and write

25. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Upright supine position
Vitamin B12 deficiency
Clonidine will take care both high bp and withdrawal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

26. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
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

27. dementia plus urinary incontinence
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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;
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
Normal pressure hydrocephalus

28. When headache is presenting complaint of brain tumor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
20%
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

29. medial thigh sensory loss and weakness in addcution
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Corticosteroid and acyclovir
Botulism has descending paralysis in contrast othere have ascending paralysis
Obturator n lesion

30. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Antitoxin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

31. excessive elevation of legs during walking (toe touch floor earlier than heels)
Clonidine will take care both high bp and withdrawal
Distal lower motor neuron disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Acetylecholinersterase inhibitors

32. Should we tx htn in acute ischemic stroke

33. How to differentiate medial and lateral pontine syndrome
Spastic paraparesis
MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

34. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
RBC count >6000
IVIG and plasmapheresis
Nystagmus on far lateral gaze
Upright supine position

35. How to stop antiepileptic drugs
Vitamin B12 deficiency
Taper gradually to prevent seizure relapse
Diabetes insipidus
Antitoxin

36. How to confirm braindeath?
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Difficulty in writing - calculating - distinguishing left and write
Clonidine will take care both high bp and withdrawal
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.

37. cortical lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aphasia - neglect - agnosia - acalculia etc
82% specific for dementia

38. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spastic paraparesis
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
20%

39. oligoclonal band in CSF
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS
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
Vitamin B12 deficiency

40. What is pronator drift
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Vitamin B12 deficiency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

41. brain stem lesion
Diabetes insipidus
Deficit in cranial nerve function
Coronary artery disease
Wernicke's encephalopathy; due to thiamine definition; medical emergency

42. severe headache and high BP
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Antitoxin
Despite the term neuroma they arise from schwann cells - schwanoma

43. How to tx acute exacerbation of MS
Cerebellar lesion
High dose IV methyleprednisone;
Taper gradually to prevent seizure relapse
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

44. When to suspect traumatic LP
Vitamin B12 deficiency
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
RBC count >6000
Clonidine will take care both high bp and withdrawal

45. phenytoin and OCP
Verapamil
Reduced efficacy of OCP
Difficulty in writing - calculating - distinguishing left and write
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

46. labyrinthitis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Get up from chair walk a short distance turn around and sit; screening test for fall
Nystagmus on far lateral gaze
Follows viral illness; vertigo - tinnitus - nausea. self limiting

47. How to differentiate parkinson and benign essential tremor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Verapamil

48. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
20%
Cerebellar lesion
MS
Antitoxin

49. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

50. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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.
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin