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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. infections in GBS
Coronary artery disease
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV
Despite the term neuroma they arise from schwann cells - schwanoma

2. Why V12 deficient develop hypokalemia after tx with b12
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

3. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Cerebral palsy; dx mri
Entacapone - COMT inhibitor
Diabetes insipidus

4. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
High dose IV methyleprednisone;

5. stroke with lower facial palsy - pronator drift despite on aspirin
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.
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

6. differentiate picks and huntington
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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

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

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8. When headache is presenting complaint of brain tumor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Gilberts disease
Cholinesterase inhibitor; and antiparkinsonism drugs

9. What percent of dementia is reversible
Corticosteroid and acyclovir
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
20%
IVIG and plasmapheresis

10. How to differentiate botulism from tick born paralysis - GBS and MG
Cerebral palsy; dx mri
Entacapone - COMT inhibitor
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
Botulism has descending paralysis in contrast othere have ascending paralysis

11. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Wernicke's encephalopathy; due to thiamine definition; medical emergency
<20; if patient scores >25 benign forgetfulness
Deficit in cranial nerve function

12. phenytoin and OCP
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
High dose IV methyleprednisone;
Reduced efficacy of OCP
Botulism has descending paralysis in contrast othere have ascending paralysis

13. acoustic neuroma
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Despite the term neuroma they arise from schwann cells - schwanoma
<20; if patient scores >25 benign forgetfulness

14. dementia plus urinary incontinence
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebral palsy; dx mri
Normal pressure hydrocephalus

15. What mmse score suggest dementia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
<20; if patient scores >25 benign forgetfulness
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.
Aphasia - neglect - agnosia - acalculia etc

16. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
EPV - campylobacter - HSV
Normal pressure hydrocephalus
Cerebellar lesion
Get up from chair walk a short distance turn around and sit; screening test for fall

17. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Reduced efficacy of OCP
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

18. excessive elevation of legs during walking (toe touch floor earlier than heels)
Coronary artery disease
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
Distal lower motor neuron disease
82% specific for dementia

19. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000
Autospy gold standard

20. cluster headache
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Obturator n lesion

21. benign essential tremor
Clonidine will take care both high bp and withdrawal
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
Follows viral illness; vertigo - tinnitus - nausea. self limiting

22. When to use brain spect scintigraphy to confirm brain death
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
It patient has electrolyte imbalance and hypothermia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

23. What is pronator drift
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Autospy gold standard
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

24. How to tx lewy body dementia
Gilberts disease
Reduced efficacy of OCP
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;
Cholinesterase inhibitor; and antiparkinsonism drugs

25. lesion in dominant parietal lobe
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Difficulty in writing - calculating - distinguishing left and write
Obturator n lesion
High dose IV methyleprednisone;

26. How to differentiate dementias
Upright supine position
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Cholinesterase inhibitor; and antiparkinsonism drugs
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

27. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Coronary artery disease
Autospy gold standard
Upright supine position

28. dominant parietal lobe on the left side
Botulism has descending paralysis in contrast othere have ascending paralysis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
90% of right handed and 60% of left handed persons; speech and language function
Despite the term neuroma they arise from schwann cells - schwanoma

29. GBS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP
IVIG and plasmapheresis

30. How to manage stroke patient came within 4 hours
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Lesion in nondominant temporal lobe

31. contraindication of sumatripta
Entacapone - COMT inhibitor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Coronary artery disease
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

32. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
IVIG and plasmapheresis
Spastic paraparesis
<20; if patient scores >25 benign forgetfulness
Cerebral palsy; dx mri

33. How to differentiate medial and lateral medullary syndrome
Obturator n lesion
High dose IV methyleprednisone;
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;
Construction apraxia; lesion in non dominant parietal lobe (right)

34. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in writing - calculating - distinguishing left and write
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
High dose IV methyleprednisone;

35. MMSE score of less than 24
Obturator n lesion
82% specific for dementia
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;
Myasthenia; due to autoantibodies against acetylecholine receptor;

36. impaired vibration and increased DTR
EPV - campylobacter - HSV
Normal pressure hydrocephalus
Vitamin B12 deficiency
Gilberts disease

37. Tx of bells palsy
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Corticosteroid and acyclovir
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
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

38. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Corticosteroid and acyclovir
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS

39. When to start fibrinolytic therapy in stroke patient?
Acetylecholinersterase inhibitors
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Corticosteroid and acyclovir
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

40. 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
Aphasia - neglect - agnosia - acalculia etc
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Femoral n lesion

41. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Nystagmus on far lateral gaze
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
Tunnel vision - diaphoresis - nausea - pallor

42. botulism
Normal pressure hydrocephalus
Antitoxin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Aspirin - control HTN and swallow eval before giving any oral meds

43. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acetylecholinersterase inhibitors
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
High dose IV methyleprednisone;

44. 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
IVIG and plasmapheresis
Distal lower motor neuron disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

45. 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
Propranolol or primidone
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

46. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

47. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Lesion in nondominant temporal lobe

48. best diagnosis for parkinsonim
Acetylecholinersterase inhibitors
Autospy gold standard
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

49. craniopharyngioma
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Antitoxin
Diabetes insipidus

50. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in writing - calculating - distinguishing left and write

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USMLE Step3 Neurology

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