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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. cortical lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Gilberts disease
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aphasia - neglect - agnosia - acalculia etc

2. When to use dopamine agonist pramipexol in parkinson
Upright supine position
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Diabetes insipidus
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

3. botulism
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
Antitoxin
Aphasia - neglect - agnosia - acalculia etc

4. dominant parietal lobe on the left side
Verapamil
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebellar lesion

5. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Nystagmus on far lateral gaze
Wernicke's encephalopathy; due to thiamine definition; medical emergency
90% of right handed and 60% of left handed persons; speech and language function

6. labyrinthitis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
<20; if patient scores >25 benign forgetfulness
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Not within 24 hours; give afte 24-48 hours if patient stable

7. How to differentiate medial and lateral medullary syndrome
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;
Tunnel vision - diaphoresis - nausea - pallor
Femoral n lesion
82% specific for dementia

8. impaired vibration and increased DTR
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Vitamin B12 deficiency
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 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.

9. 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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

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

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11. infections in GBS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse
EPV - campylobacter - HSV
82% specific for dementia

12. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Despite the term neuroma they arise from schwann cells - schwanoma
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebral palsy; dx mri

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

14. at first tingling in toes and feet then weakness in extremities
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease

15. medial thigh sensory loss and weakness in addcution
Vitamin B12 deficiency
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
Obturator n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

16. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Botulism has descending paralysis in contrast othere have ascending paralysis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

17. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Propranolol or primidone
20%
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

18. MG
Entacapone - COMT inhibitor
Coronary artery disease
Acetylecholinersterase inhibitors
Upright supine position

19. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Upright supine position
Botulism has descending paralysis in contrast othere have ascending paralysis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

20. How to differentiate medial and lateral pontine syndrome
Get up from chair walk a short distance turn around and sit; screening test for fall
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
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

21. When to give aspirin when patient on tPA after stroke
Vitamin B12 deficiency
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
EPV - campylobacter - HSV
Not within 24 hours; give afte 24-48 hours if patient stable

22. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

23. Tx of GBS
It patient has electrolyte imbalance and hypothermia
Get up from chair walk a short distance turn around and sit; screening test for fall
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

24. What is pronator drift
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Clonidine will take care both high bp and withdrawal

25. acoustic neuroma
Vitamin B12 deficiency
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Despite the term neuroma they arise from schwann cells - schwanoma
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

26. When to use brain spect scintigraphy to confirm brain death
Propranolol or primidone
It patient has electrolyte imbalance and hypothermia
Taper gradually to prevent seizure relapse
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

27. prodrome of vasovagal syncope
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Distal lower motor neuron disease

28. What is can be used cluster headache prevention
Nystagmus on far lateral gaze
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
Verapamil
Vitamin B12 deficiency

29. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Gilberts disease
IVIG and plasmapheresis
Botulism has descending paralysis in contrast othere have ascending paralysis

30. stroke with lower facial palsy - pronator drift despite on aspirin
EPV - campylobacter - HSV
<20; if patient scores >25 benign forgetfulness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

31. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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.
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Vitamin B12 deficiency
Nystagmus on far lateral gaze

32. 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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS
<20; if patient scores >25 benign forgetfulness

33. differentiate wenicke and korsakoff
RBC count >6000
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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;

34. Should we tx htn in acute ischemic stroke

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35. GBS
IVIG and plasmapheresis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
RBC count >6000

36. korsafoff psychosis
Botulism has descending paralysis in contrast othere have ascending paralysis
IVIG and plasmapheresis
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

37. impaired perception of complex sounds
Get up from chair walk a short distance turn around and sit; screening test for fall
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Lesion in nondominant temporal lobe

38. How to differentiate parkinson and benign essential tremor
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Clonidine will take care both high bp and withdrawal

39. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aspirin - control HTN and swallow eval before giving any oral meds
Taper gradually to prevent seizure relapse
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

40. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

41. How to perform apnea test
Vitamin B12 deficiency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spastic paraparesis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

42. what drug is used to extend effects of levodopa
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
Entacapone - COMT inhibitor
Get up from chair walk a short distance turn around and sit; screening test for fall

43. 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
Aphasia - neglect - agnosia - acalculia etc
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

44. How to stop antiepileptic drugs
82% specific for 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
Taper gradually to prevent seizure relapse
Not within 24 hours; give afte 24-48 hours if patient stable

45. What mmse score suggest dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Entacapone - COMT inhibitor
<20; if patient scores >25 benign forgetfulness
Construction apraxia; lesion in non dominant parietal lobe (right)

46. How to tx acute exacerbation of MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
High dose IV methyleprednisone;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Normal pressure hydrocephalus

47. 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
Cerebral palsy; dx mri
Upright supine position
Antitoxin

48. MMSE score of less than 24
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Acetylecholinersterase inhibitors
82% specific for dementia
High dose IV methyleprednisone;

49. earliest sign of phenytoin toxicity
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Get up from chair walk a short distance turn around and sit; screening test for fall
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Nystagmus on far lateral gaze

50. oligoclonal band in CSF
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
MS
Propranolol or primidone
Gilberts disease

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USMLE Step3 Neurology

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