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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. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Antitoxin
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Deficit in cranial nerve function
Not within 24 hours; give afte 24-48 hours if patient stable

2. impaired hepatic conjugation of billirubin
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Gilberts disease
EPV - campylobacter - HSV
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

3. anerior and anteriomedial thigh paresthesia - decreased DTR
20%
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
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

4. When to use dopamine agonist pramipexol in parkinson
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Not within 24 hours; give afte 24-48 hours if patient stable
Femoral n lesion

5. severe headache and high BP
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
Antitoxin
Lesion in nondominant temporal lobe

6. dominant parietal lobe on the left side
EPV - campylobacter - HSV
90% of right handed and 60% of left handed persons; speech and language function
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

7. acoustic neuroma
Cholinesterase inhibitor; and antiparkinsonism drugs
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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 lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Aphasia - neglect - agnosia - acalculia etc
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;

9. women with unilateral eye pain; neurlogic symptoms here there at different times
IVIG and plasmapheresis
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

10. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

11. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Coronary artery disease
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

12. When to give aspirin when patient on tPA after stroke
90% of right handed and 60% of left handed persons; speech and language function
Cerebellar lesion
Not within 24 hours; give afte 24-48 hours if patient stable
Diabetes insipidus

13. medial thigh sensory loss and weakness in addcution
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Autospy gold standard
Obturator n lesion

14. How to tx stroke patient came after 6h
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aspirin - control HTN and swallow eval before giving any oral meds
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

15. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
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
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

16. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

17. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Distal lower motor neuron disease
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

18. Why V12 deficient develop hypokalemia after tx with b12
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Autospy gold standard

19. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
90% of right handed and 60% of left handed persons; speech and language function
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

20. 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
Corticosteroid and acyclovir
Cerebral palsy; dx mri
Get up from chair walk a short distance turn around and sit; screening test for fall

21. What is pronator drift
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Botulism has descending paralysis in contrast othere have ascending paralysis

22. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebral palsy; dx mri
Get up from chair walk a short distance turn around and sit; screening test for fall
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

23. Should we tx htn in acute ischemic stroke

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24. Tx of GBS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Despite the term neuroma they arise from schwann cells - schwanoma
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

25. contraindication of sumatripta
Coronary artery disease
Normal pressure hydrocephalus
Botulism has descending paralysis in contrast othere have ascending paralysis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

26. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Taper gradually to prevent seizure relapse
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

27. When to suspect traumatic LP
Botulism has descending paralysis in contrast othere have ascending paralysis
RBC count >6000
Spastic paraparesis
Despite the term neuroma they arise from schwann cells - schwanoma

28. at first tingling in toes and feet then weakness in extremities
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease

29. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
<20; if patient scores >25 benign forgetfulness
Follows viral illness; vertigo - tinnitus - nausea. self limiting

30. oligoclonal band in CSF
MS
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Wernicke's encephalopathy; due to thiamine definition; medical emergency

31. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Obturator n lesion
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

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

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33. How to differentiate botulism from tick born paralysis - GBS and MG
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
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

34. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
High dose IV methyleprednisone;
Aphasia - neglect - agnosia - acalculia etc

35. How to tx acute exacerbation of MS
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Nystagmus on far lateral gaze

36. impaired vibration and increased DTR
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Despite the term neuroma they arise from schwann cells - schwanoma
Vitamin B12 deficiency
Tunnel vision - diaphoresis - nausea - pallor

37. indication of plasmapheresis in 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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

38. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Tunnel vision - diaphoresis - nausea - pallor
Corticosteroid and acyclovir

39. labyrinthitis
Entacapone - COMT inhibitor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

41. MMSE score of less than 24
Taper gradually to prevent seizure relapse
Acetylecholinersterase inhibitors
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
82% specific for dementia

42. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Spastic paraparesis
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

43. MG
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Acetylecholinersterase inhibitors
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

44. lesion in dominant tempora lobe
Lesion in nondominant temporal lobe
Coronary artery disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

45. craniopharyngioma
Construction apraxia; lesion in non dominant parietal lobe (right)
Diabetes insipidus
High dose IV methyleprednisone;
Femoral n lesion

46. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Aspirin - control HTN and swallow eval before giving any oral meds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Get up from chair walk a short distance turn around and sit; screening test for fall

47. cortical lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Normal pressure hydrocephalus
Aphasia - neglect - agnosia - acalculia etc

48. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors
Obturator n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

49. korsafoff psychosis
Acetylecholinersterase inhibitors
Deficit in cranial nerve function
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

50. 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
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Wernicke's encephalopathy; due to thiamine definition; medical emergency

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USMLE Step3 Neurology

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