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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. 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
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Myasthenia; due to autoantibodies against acetylecholine receptor;

2. Why V12 deficient develop hypokalemia after tx with b12
Vitamin B12 deficiency
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

3. impaired perception of complex sounds
Lesion in nondominant temporal lobe
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

4. indication of plasmapheresis in GBS
82% specific for dementia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds

5. impaired vibration and increased DTR
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Normal pressure hydrocephalus

6. What is can be used cluster headache prevention
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Botulism has descending paralysis in contrast othere have ascending paralysis
Verapamil

7. women with unilateral eye pain; neurlogic symptoms here there at different times
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

8. How to tx stroke patient came after 6h
Normal pressure hydrocephalus
Aspirin - control HTN and swallow eval before giving any oral meds
RBC count >6000
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

9. When to use dopamine agonist pramipexol in parkinson
Obturator n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

10. differentiate lewy body dementia and vascular dementia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Cerebral palsy; dx mri
Deficit in cranial nerve function

11. oligoclonal band in CSF
Taper gradually to prevent seizure relapse
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Difficulty in writing - calculating - distinguishing left and write
MS

12. Blood transfusion in hypothermia
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
Gilberts disease
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

13. What percent of dementia is reversible
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.
Cerebral palsy; dx mri
Taper gradually to prevent seizure relapse
20%

14. labyrinthitis
Botulism has descending paralysis in contrast othere have ascending paralysis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Get up from chair walk a short distance turn around and sit; screening test for fall

15. prodrome of vasovagal syncope
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tunnel vision - diaphoresis - nausea - pallor
Wernicke's encephalopathy; due to thiamine definition; medical emergency
IVIG and plasmapheresis

16. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Despite the term neuroma they arise from schwann cells - schwanoma
Myasthenia; due to autoantibodies against acetylecholine receptor;
Upright supine position

17. How to differentiate medial and lateral pontine syndrome
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
Construction apraxia; lesion in non dominant parietal lobe (right)

18. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Spastic paraparesis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

19. How to tx lewy body dementia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cholinesterase inhibitor; and antiparkinsonism drugs
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.

20. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
82% specific for dementia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir

21. what drug is used to extend effects of levodopa
Clonidine will take care both high bp and withdrawal
Entacapone - COMT inhibitor
Cholinesterase inhibitor; and antiparkinsonism drugs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

22. korsafoff psychosis
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 glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebellar lesion
Gilberts disease

23. differentiate picks and huntington
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
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
Cerebellar lesion

24. When to suspect traumatic LP
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.
Get up from chair walk a short distance turn around and sit; screening test for fall
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000

25. How to stop antiepileptic drugs
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;
Normal pressure hydrocephalus
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse

26. Tx of bells palsy
90% of right handed and 60% of left handed persons; speech and language function
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
Cerebellar lesion

27. contraindication of sumatripta
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Coronary artery disease
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

28. How to differentiate botulism from tick born paralysis - GBS and MG
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Coronary artery disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Tunnel vision - diaphoresis - nausea - pallor

29. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
High dose IV methyleprednisone;

30. get up and go test
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
Get up from chair walk a short distance turn around and sit; screening test for fall
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

31. Tx of GBS
Nystagmus on far lateral gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Entacapone - COMT inhibitor

32. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Acetylecholinersterase inhibitors
Follows viral illness; vertigo - tinnitus - nausea. self limiting

33. How to confirm braindeath?
EPV - campylobacter - HSV
Femoral n lesion
Cerebral palsy; dx mri
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.

34. How to tx acute exacerbation of MS
IVIG and plasmapheresis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
High dose IV methyleprednisone;
Reduced efficacy of OCP

35. cortical lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acetylecholinersterase inhibitors
Aphasia - neglect - agnosia - acalculia etc

36. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
20%
High dose IV methyleprednisone;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

37. MMSE score of less than 24
Cerebral palsy; dx mri
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

38. 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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Myasthenia; due to autoantibodies against acetylecholine receptor;

39. How to differentiate dementias
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Get up from chair walk a short distance turn around and sit; screening test for fall
Aspirin - control HTN and swallow eval before giving any oral meds

40. medial thigh sensory loss and weakness in addcution
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Obturator n lesion

41. cluster headache
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
Cerebral palsy; dx mri
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

42. 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;
Verapamil
Distal lower motor neuron disease

43. phenytoin and OCP
Construction apraxia; lesion in non dominant parietal lobe (right)
Gilberts disease
Lesion in nondominant temporal lobe
Reduced efficacy of OCP

44. GBS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis
Cerebral palsy; dx mri
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

45. botulism
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Antitoxin

46. Patient with carbamazepine; What should be advice?
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Entacapone - COMT inhibitor

47. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebral palsy; dx mri
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Clonidine will take care both high bp and withdrawal

48. Acute onset of left arm weakness
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cholinesterase inhibitor; and antiparkinsonism drugs
Antitoxin

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

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50. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Gilberts disease
<20; if patient scores >25 benign forgetfulness
Corticosteroid and acyclovir