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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. impaired vibration and increased DTR
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Botulism has descending paralysis in contrast othere have ascending paralysis

2. prodrome of vasovagal syncope
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
Diabetes insipidus
Get up from chair walk a short distance turn around and sit; screening test for fall
Tunnel vision - diaphoresis - nausea - pallor

3. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Cholinesterase inhibitor; and antiparkinsonism drugs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

4. Why V12 deficient develop hypokalemia after tx with b12
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
Lesion in nondominant temporal lobe
Not within 24 hours; give afte 24-48 hours if patient stable
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

5. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

6. benign essential tremor
MS
It patient has electrolyte imbalance and hypothermia
Propranolol or primidone
Obturator n lesion

7. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Clonidine will take care both high bp and withdrawal
20%
Upright supine position
Reduced efficacy of OCP

8. impaired perception of complex sounds
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Construction apraxia; lesion in non dominant parietal lobe (right)
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Lesion in nondominant temporal lobe

9. How to confirm braindeath?
Construction apraxia; lesion in non dominant parietal lobe (right)
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.
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
RBC count >6000

10. korsafoff psychosis
Normal pressure hydrocephalus
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Taper gradually to prevent seizure relapse
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

11. craniopharyngioma
Diabetes insipidus
Autospy gold standard
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in writing - calculating - distinguishing left and write

12. When headache is presenting complaint of brain tumor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Acetylecholinersterase inhibitors
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

13. When to start fibrinolytic therapy in stroke patient?
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
EPV - campylobacter - HSV
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

14. What is pronator drift
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

15. How to prevent prevent frequency of MS exacerbation
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

16. What is can be used cluster headache prevention
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Gilberts disease
90% of right handed and 60% of left handed persons; speech and language function
Verapamil

17. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Coronary artery disease
Cerebellar lesion
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

18. How to tx lewy body dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cholinesterase inhibitor; and antiparkinsonism drugs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP

19. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
It patient has electrolyte imbalance and hypothermia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion

20. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Reduced efficacy of OCP
Vitamin B12 deficiency
Wernicke's encephalopathy; due to thiamine definition; medical emergency

21. dementia plus urinary incontinence
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Gilberts disease
Obturator n lesion
Normal pressure hydrocephalus

22. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
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
Antitoxin

23. best diagnosis for parkinsonim
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Autospy gold standard
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

24. oligoclonal band in CSF
MS
90% of right handed and 60% of left handed persons; speech and language function
Lesion in nondominant temporal lobe
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

25. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Clonidine will take care both high bp and withdrawal
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Lesion in nondominant temporal lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

26. acoustic neuroma
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
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write
Despite the term neuroma they arise from schwann cells - schwanoma

27. what drug is used to extend effects of levodopa
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Reduced efficacy of OCP
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Entacapone - COMT inhibitor

28. phenytoin and OCP
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Reduced efficacy of OCP
Propranolol or primidone
Lesion in nondominant temporal lobe

29. Patient with carbamazepine; What should be advice?
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

30. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Clonidine will take care both high bp and withdrawal
Spastic paraparesis
Myasthenia; due to autoantibodies against acetylecholine receptor;

31. differentiate picks and huntington
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
Upright supine position
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function

32. impaired hepatic conjugation of billirubin
Gilberts disease
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
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
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

33. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
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.
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Vitamin B12 deficiency

34. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Aphasia - neglect - agnosia - acalculia etc
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Wernicke's encephalopathy; due to thiamine definition; medical emergency

35. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

36. labyrinthitis
Despite the term neuroma they arise from schwann cells - schwanoma
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

37. What percent of dementia is reversible
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal
20%
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.

38. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Reduced efficacy of OCP
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

39. severe headache and high BP
Gilberts disease
Acetylecholinersterase inhibitors
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

40. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Taper gradually to prevent seizure relapse
Myasthenia; due to autoantibodies against acetylecholine receptor;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

41. women with unilateral eye pain; neurlogic symptoms here there at different times
Femoral n lesion
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;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

42. Should we tx htn in acute ischemic stroke

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43. infections in GBS
20%
Reduced efficacy of OCP
Clonidine will take care both high bp and withdrawal
EPV - campylobacter - HSV

44. Blood transfusion in hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Obturator 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.
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

45. dominant parietal lobe on the left side
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
90% of right handed and 60% of left handed persons; speech and language function
Coronary artery disease
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

46. When to use dopamine agonist pramipexol in parkinson
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

47. cluster headache
Verapamil
Not within 24 hours; give afte 24-48 hours if patient stable
Femoral n lesion
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

48. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Corticosteroid and acyclovir
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
90% of right handed and 60% of left handed persons; speech and language function

49. When to use brain spect scintigraphy to confirm brain death
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
It patient has electrolyte imbalance and hypothermia
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

50. differentiate wenicke and korsakoff
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
<20; if patient scores >25 benign forgetfulness
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

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USMLE Step3 Neurology

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