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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. When to use dopamine agonist pramipexol in parkinson
Deficit in cranial nerve function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

2. anerior and anteriomedial thigh paresthesia - decreased DTR
Upright supine position
Distal lower motor neuron disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Femoral n lesion

3. stroke with lower facial palsy - pronator drift despite on aspirin
Myasthenia; due to autoantibodies against acetylecholine receptor;
Nystagmus on far lateral gaze
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

4. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
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

5. brain stem lesion
Deficit in cranial nerve function
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

6. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
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
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis

7. 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
Acetylecholinersterase inhibitors
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

8. excessive elevation of legs during walking (toe touch floor earlier than heels)
MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Distal lower motor neuron disease
Propranolol or primidone

9. what drug is used to extend effects of levodopa
Vitamin B12 deficiency
Cerebral palsy; dx mri
Entacapone - COMT inhibitor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

10. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
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
Aphasia - neglect - agnosia - acalculia etc

11. differentiate lewy body dementia and vascular dementia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

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

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13. When to give aspirin when patient on tPA after stroke
<20; if patient scores >25 benign forgetfulness
Spastic paraparesis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Not within 24 hours; give afte 24-48 hours if patient stable

14. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Normal pressure hydrocephalus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Entacapone - COMT inhibitor

15. dementia plus urinary incontinence
Difficulty in writing - calculating - distinguishing left and write
Gilberts disease
Normal pressure hydrocephalus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

16. How to prevent prevent frequency of MS exacerbation
Aphasia - neglect - agnosia - acalculia etc
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Taper gradually to prevent seizure relapse
Spastic paraparesis

17. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Obturator n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Aspirin - control HTN and swallow eval before giving any oral meds

18. phenytoin and OCP
Normal pressure hydrocephalus
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
High dose IV methyleprednisone;

19. craniopharyngioma
82% specific for dementia
Diabetes insipidus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Vitamin B12 deficiency

20. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Antitoxin
Difficulty in writing - calculating - distinguishing left and write
Femoral n lesion

21. How to tx lewy body dementia
Cerebellar lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000
Corticosteroid and acyclovir

22. impaired hepatic conjugation of billirubin
Gilberts disease
Reduced efficacy of OCP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

23. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Clonidine will take care both high bp and withdrawal
<20; if patient scores >25 benign forgetfulness

24. Tx of GBS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aphasia - neglect - agnosia - acalculia etc
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

25. acoustic neuroma
Gilberts disease
Despite the term neuroma they arise from schwann cells - schwanoma
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

26. severe headache and high BP
Nystagmus on far lateral gaze
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Verapamil
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

27. women with unilateral eye pain; neurlogic symptoms here there at different times
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
It patient has electrolyte imbalance and hypothermia

28. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Tunnel vision - diaphoresis - nausea - pallor
Femoral n lesion
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

29. How to manage stroke patient came within 4 hours
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
RBC count >6000
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

30. Patient with carbamazepine; What should be advice?
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Normal pressure hydrocephalus

31. MMSE score of less than 24
It patient has electrolyte imbalance and hypothermia
82% specific for dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

32. 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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spastic paraparesis
Reduced efficacy of OCP

33. How to differentiate traumatic LP and SAH
Taper gradually to prevent seizure relapse
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

34. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Get up from chair walk a short distance turn around and sit; screening test for fall
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Gilberts disease

35. prodrome of vasovagal syncope
RBC count >6000
Tunnel vision - diaphoresis - nausea - pallor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease

36. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

37. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Deficit in cranial nerve function
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

38. How to tx stroke patient came after 6h
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aspirin - control HTN and swallow eval before giving any oral meds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

39. When to start fibrinolytic therapy in stroke patient?
Cerebellar lesion
Propranolol or primidone
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

40. double vision at the end of day and ptosis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Lesion in nondominant temporal lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

41. contraindication of sumatripta
<20; if patient scores >25 benign forgetfulness
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Autospy gold standard
Coronary artery disease

42. When to suspect traumatic LP
Verapamil
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
RBC count >6000
Taper gradually to prevent seizure relapse

43. GBS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
<20; if patient scores >25 benign forgetfulness
IVIG and plasmapheresis
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

44. lesion in dominant tempora lobe
Distal lower motor neuron disease
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

45. botulism
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
Antitoxin
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

46. How to differentiate medial and lateral medullary syndrome
Cerebral palsy; dx mri
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;
Difficulty in writing - calculating - distinguishing left and write
It patient has electrolyte imbalance and hypothermia

47. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;
Nystagmus on far lateral gaze

48. 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
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aphasia - neglect - agnosia - acalculia etc

49. How to stop antiepileptic drugs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus
Taper gradually to prevent seizure relapse

50. How to tx acute exacerbation of MS
IVIG and plasmapheresis
Reduced efficacy of OCP
High dose IV methyleprednisone;
Verapamil

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USMLE Step3 Neurology

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