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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. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Construction apraxia; lesion in non dominant parietal lobe (right)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

2. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tunnel vision - diaphoresis - nausea - pallor

3. at first tingling in toes and feet then weakness in extremities
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Coronary artery disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

4. What bp med to be given in a patient with high bp and signs of opioid withdrawal
82% specific for dementia
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
Clonidine will take care both high bp and withdrawal

5. How to manage stroke patient came within 4 hours
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Entacapone - COMT inhibitor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

6. differentiate picks and huntington
Diabetes insipidus
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Cholinesterase inhibitor; and antiparkinsonism drugs

7. benign essential tremor
Despite the term neuroma they arise from schwann cells - schwanoma
Propranolol or primidone
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Follows viral illness; vertigo - tinnitus - nausea. self limiting

8. How to tx lewy body dementia
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
Normal pressure hydrocephalus
Spastic paraparesis
Cholinesterase inhibitor; and antiparkinsonism drugs

9. korsafoff psychosis
Femoral n lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

10. MG
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Construction apraxia; lesion in non dominant parietal lobe (right)
Acetylecholinersterase inhibitors
Taper gradually to prevent seizure relapse

11. How to differentiate medial and lateral pontine syndrome
Distal lower motor neuron disease
MS
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;
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

12. dementia plus urinary incontinence
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
Normal pressure hydrocephalus
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
Deficit in cranial nerve function

13. Tx of GBS
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

14. When to start fibrinolytic therapy in stroke patient?
Myasthenia; due to autoantibodies against acetylecholine receptor;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Deficit in cranial nerve function
IVIG and plasmapheresis

15. How to differentiate botulism from tick born paralysis - GBS and MG
Antitoxin
Botulism has descending paralysis in contrast othere have ascending paralysis
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

16. How to prevent prevent frequency of MS exacerbation
Gilberts disease
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Clonidine will take care both high bp and withdrawal

17. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Vitamin B12 deficiency
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;

18. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
It patient has electrolyte imbalance and hypothermia
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
Cerebellar lesion
MS

19. medial thigh sensory loss and weakness in addcution
Vitamin B12 deficiency
Obturator n lesion
Cerebellar lesion
MS

20. How to differentiate medial and lateral medullary syndrome
Deficit in cranial nerve function
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 understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

21. prodrome of vasovagal syncope
Distal lower motor neuron disease
Tunnel vision - diaphoresis - nausea - pallor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

22. Blood transfusion in hypothermia
82% specific for dementia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Verapamil
Entacapone - COMT inhibitor

23. cluster headache
Tunnel vision - diaphoresis - nausea - pallor
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

24. Tx of bells palsy
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
Femoral n lesion
20%

25. dominant parietal lobe on the left side
20%
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
90% of right handed and 60% of left handed persons; speech and language function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

26. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

27. best diagnosis for parkinsonim
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acetylecholinersterase inhibitors
Autospy gold standard
Femoral n lesion

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

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29. contraindication of sumatripta
Coronary artery disease
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;
Verapamil
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

30. acoustic neuroma
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
Femoral n lesion
Despite the term neuroma they arise from schwann cells - schwanoma
Distal lower motor neuron disease

31. What mmse score suggest dementia
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
Vitamin B12 deficiency
<20; if patient scores >25 benign forgetfulness
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

32. When to suspect traumatic LP
RBC count >6000
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

33. lesion in dominant parietal lobe
90% of right handed and 60% of left handed persons; speech and language function
Botulism has descending paralysis in contrast othere have ascending paralysis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in writing - calculating - distinguishing left and write

34. Should we tx htn in acute ischemic stroke

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35. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

36. double vision at the end of day and ptosis
It patient has electrolyte imbalance and hypothermia
Autospy gold standard
Aspirin - control HTN and swallow eval before giving any oral meds
Myasthenia; due to autoantibodies against acetylecholine receptor;

37. How to differentiate dementias
Deficit in cranial nerve function
Lesion in nondominant temporal lobe
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Clonidine will take care both high bp and withdrawal

38. Unable to copy of matchstick - unable to dress up
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

39. impaired perception of complex sounds
Diabetes insipidus
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebellar lesion
Lesion in nondominant temporal lobe

40. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Entacapone - COMT inhibitor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Lesion in nondominant temporal lobe

41. Why V12 deficient develop hypokalemia after tx with b12
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
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Not within 24 hours; give afte 24-48 hours if patient stable

42. stroke with lower facial palsy - pronator drift despite on aspirin
Myasthenia; due to autoantibodies against acetylecholine receptor;
Antitoxin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

43. How to perform apnea test
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

44. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Gilberts disease
Coronary artery disease
Spastic paraparesis

45. Patient with carbamazepine; What should be advice?
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
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
Cerebellar lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

46. MMSE score of less than 24
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
82% specific for dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
MS

47. craniopharyngioma
Diabetes insipidus
Deficit in cranial nerve function
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Reduced efficacy of OCP

48. lesion in dominant tempora lobe
Corticosteroid and acyclovir
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

49. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;

50. differentiate lewy body dementia and vascular 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
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 writing - calculating - distinguishing left and write
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

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USMLE Step3 Neurology

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