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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. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Lesion in nondominant temporal lobe
Cerebellar lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

2. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Spastic paraparesis

3. anerior and anteriomedial thigh paresthesia - decreased DTR
Botulism has descending paralysis in contrast othere have ascending paralysis
Femoral n lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Clonidine will take care both high bp and withdrawal

4. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Get up from chair walk a short distance turn around and sit; screening test for fall
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting

5. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
It patient has electrolyte imbalance and hypothermia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Autospy gold standard
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

6. infections in GBS
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
EPV - campylobacter - HSV
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
<20; if patient scores >25 benign forgetfulness

7. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Verapamil
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Antitoxin

8. Tx of bells palsy
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Not within 24 hours; give afte 24-48 hours if patient stable
Corticosteroid and acyclovir
82% specific for dementia

9. lesion in dominant parietal lobe
Lesion in nondominant temporal lobe
Cerebral palsy; dx mri
Difficulty in writing - calculating - distinguishing left and write
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

10. How to tx stroke patient came after 6h
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in writing - calculating - distinguishing left and write
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aspirin - control HTN and swallow eval before giving any oral meds

11. botulism
Antitoxin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Obturator n lesion

12. medial thigh sensory loss and weakness in addcution
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Obturator n lesion
Autospy gold standard
High dose IV methyleprednisone;

13. How to tx acute exacerbation of MS
Taper gradually to prevent seizure relapse
Nystagmus on far lateral gaze
Cholinesterase inhibitor; and antiparkinsonism drugs
High dose IV methyleprednisone;

14. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Get up from chair walk a short distance turn around and sit; screening test for fall

15. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Antitoxin
Distal lower motor neuron disease
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

16. Should we tx htn in acute ischemic stroke

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17. excessive elevation of legs during walking (toe touch floor earlier than heels)
Diabetes insipidus
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc

18. craniopharyngioma
Diabetes insipidus
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Verapamil

19. How to differentiate dementias
Entacapone - COMT inhibitor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Despite the term neuroma they arise from schwann cells - schwanoma

20. stroke with lower facial palsy - pronator drift despite on aspirin
RBC count >6000
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
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

21. Acute onset of left arm weakness
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Get up from chair walk a short distance turn around and sit; screening test for fall

22. indication of plasmapheresis in GBS
Aphasia - neglect - agnosia - acalculia etc
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
It patient has electrolyte imbalance and hypothermia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

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

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24. prodrome of vasovagal syncope
Reduced efficacy of OCP
82% specific for dementia
Autospy gold standard
Tunnel vision - diaphoresis - nausea - pallor

25. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Nystagmus on far lateral gaze

26. differentiate wenicke and korsakoff
Clonidine will take care both high bp and withdrawal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

27. MMSE score of less than 24
Aspirin - control HTN and swallow eval before giving any oral meds
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
82% specific for dementia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

28. How to stop antiepileptic drugs
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acetylecholinersterase inhibitors
MS
Taper gradually to prevent seizure relapse

29. at first tingling in toes and feet then weakness in extremities
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
IVIG and plasmapheresis
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

30. women with unilateral eye pain; neurlogic symptoms here there at different times
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
It patient has electrolyte imbalance and hypothermia
Spastic paraparesis

31. impaired vibration and increased DTR
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Vitamin B12 deficiency
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

32. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Cerebral palsy; dx mri
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Taper gradually to prevent seizure relapse

33. contraindication of sumatripta
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Coronary artery disease

34. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
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.
Verapamil
Normal pressure hydrocephalus

35. cluster headache
High dose IV methyleprednisone;
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
RBC count >6000

36. GBS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Gilberts disease
Verapamil
IVIG and plasmapheresis

37. How to differentiate traumatic LP and SAH
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
Cerebral palsy; dx mri
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

38. Patient with carbamazepine; What should be advice?
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Propranolol or primidone
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

39. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

40. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Gilberts disease
Vitamin B12 deficiency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

41. phenytoin and OCP
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Reduced efficacy of OCP

42. Tx of GBS
Acetylecholinersterase inhibitors
Tunnel vision - diaphoresis - nausea - pallor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

43. When to start fibrinolytic therapy in stroke patient?
Gilberts disease
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
EPV - campylobacter - HSV

44. What mmse score suggest dementia
EPV - campylobacter - HSV
Botulism has descending paralysis in contrast othere have ascending paralysis
<20; if patient scores >25 benign forgetfulness
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.

45. cortical lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aphasia - neglect - agnosia - acalculia etc

46. How to differentiate parkinson and benign essential tremor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
RBC count >6000

47. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Construction apraxia; lesion in non dominant parietal lobe (right)
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Spastic paraparesis

48. MG
Acetylecholinersterase inhibitors
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;

49. best diagnosis for parkinsonim
Autospy gold standard
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Entacapone - COMT inhibitor
<20; if patient scores >25 benign forgetfulness

50. When to suspect traumatic LP
RBC count >6000
Botulism has descending paralysis in contrast othere have ascending paralysis
Femoral n lesion
Reduced efficacy of OCP

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USMLE Step3 Neurology

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