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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. How to manage stroke patient came within 4 hours
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
Diabetes insipidus
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

2. differentiate wenicke and korsakoff
Clonidine will take care both high bp and withdrawal
Corticosteroid and acyclovir
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
Coronary artery disease

3. craniopharyngioma
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Upright supine position
Diabetes insipidus
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

4. Unable to copy of matchstick - unable to dress up
Get up from chair walk a short distance turn around and sit; screening test for fall
Construction apraxia; lesion in non dominant parietal lobe (right)
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;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

5. 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
Antitoxin
Reduced efficacy of OCP
90% of right handed and 60% of left handed persons; speech and language function

6. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Propranolol or primidone
Vitamin B12 deficiency
Gilberts disease
Clonidine will take care both high bp and withdrawal

7. severe headache and high BP
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acetylecholinersterase inhibitors
Propranolol or primidone

8. How to confirm braindeath?
Get up from chair walk a short distance turn around and sit; screening test for fall
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
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.
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

9. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Spastic paraparesis
Corticosteroid and acyclovir
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

10. MMSE score of less than 24
It patient has electrolyte imbalance and hypothermia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

11. oligoclonal band in CSF
MS
Get up from chair walk a short distance turn around and sit; screening test for fall
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency

12. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Verapamil
Diabetes insipidus
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. phenytoin and OCP
Tunnel vision - diaphoresis - nausea - pallor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Reduced efficacy of OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

14. lesion in dominant tempora lobe
Autospy gold standard
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write

15. korsafoff psychosis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Distal lower motor neuron disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

16. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors

17. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
It patient has electrolyte imbalance and hypothermia

18. GBS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis
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
Clonidine will take care both high bp and withdrawal

19. impaired vibration and increased DTR
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in writing - calculating - distinguishing left and write
Vitamin B12 deficiency
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

20. When to suspect traumatic LP
RBC count >6000
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Nystagmus on far lateral gaze
Antitoxin

21. What is can be used cluster headache prevention
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
Verapamil
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

22. When headache is presenting complaint of brain tumor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Lesion in nondominant temporal lobe
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

23. When to start fibrinolytic therapy in stroke patient?
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Corticosteroid and acyclovir
It patient has electrolyte imbalance and hypothermia

24. Patient with carbamazepine; What should be advice?
Myasthenia; due to autoantibodies against acetylecholine receptor;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

25. What is pronator drift
Aphasia - neglect - agnosia - acalculia etc
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

26. get up and go test
Clonidine will take care both high bp and withdrawal
82% specific for dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Get up from chair walk a short distance turn around and sit; screening test for fall

27. MG
Construction apraxia; lesion in non dominant parietal lobe (right)
Acetylecholinersterase inhibitors
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

28. prodrome of vasovagal syncope
Aspirin - control HTN and swallow eval before giving any oral meds
Cerebellar 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;
Tunnel vision - diaphoresis - nausea - pallor

29. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Lesion in nondominant temporal lobe
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.
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

30. Tx of GBS
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
Spastic paraparesis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

31. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Cerebellar lesion
Upright supine position

32. differentiate lewy body dementia and vascular dementia
Femoral n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
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
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.

33. lesion in dominant parietal lobe
Get up from chair walk a short distance turn around and sit; screening test for fall
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in writing - calculating - distinguishing left and write

34. best diagnosis for parkinsonim
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Autospy gold standard
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. Tx of bells palsy
Get up from chair walk a short distance turn around and sit; screening test for fall
Corticosteroid and acyclovir
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
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

36. Why V12 deficient develop hypokalemia after tx with b12
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
Aspirin - control HTN and swallow eval before giving any oral meds
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

37. differentiate picks and huntington
Clonidine will take care both high bp and withdrawal
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
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

38. dominant parietal lobe on the left side
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

39. Should we tx htn in acute ischemic stroke

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40. What percent of dementia is reversible
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
RBC count >6000
20%
Cerebellar lesion

41. cluster headache
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Corticosteroid and acyclovir

42. How to differentiate dementias
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Spastic paraparesis
Antitoxin

43. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Aspirin - control HTN and swallow eval before giving any oral meds
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

44. When to use brain spect scintigraphy to confirm brain death
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Propranolol or primidone

45. contraindication of sumatripta
Construction apraxia; lesion in non dominant parietal lobe (right)
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write
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

46. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Upright supine position
Coronary artery disease

47. indication of plasmapheresis in GBS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

48. stroke with lower facial palsy - pronator drift despite on aspirin
Deficit in cranial nerve function
MS
IVIG and plasmapheresis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

49. How to differentiate botulism from tick born paralysis - GBS and MG
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Botulism has descending paralysis in contrast othere have ascending paralysis
Entacapone - COMT inhibitor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

50. How to differentiate medial and lateral pontine syndrome
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Femoral n lesion
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

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USMLE Step3 Neurology

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