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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. anerior and anteriomedial thigh paresthesia - decreased DTR
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Femoral n lesion
Nystagmus on far lateral gaze

2. MMSE score of less than 24
Vitamin B12 deficiency
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
82% specific for dementia

3. differentiate picks and huntington
Myasthenia; due to autoantibodies against acetylecholine receptor;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Aspirin - control HTN and swallow eval before giving any oral meds

4. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Cerebellar lesion
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

5. What percent of dementia is reversible
Vitamin B12 deficiency
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
20%

6. How to tx lewy body 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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Antitoxin
Cholinesterase inhibitor; and antiparkinsonism drugs

7. Blood transfusion in hypothermia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acetylecholinersterase inhibitors
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aspirin - control HTN and swallow eval before giving any oral meds

8. When to use dopamine agonist pramipexol in parkinson
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
EPV - campylobacter - HSV
Botulism has descending paralysis in contrast othere have ascending paralysis

9. phenytoin and OCP
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Distal lower motor neuron disease
Reduced efficacy of OCP
Autospy gold standard

10. dementia plus urinary incontinence
Entacapone - COMT inhibitor
Normal pressure hydrocephalus
Aspirin - control HTN and swallow eval before giving any oral meds
Clonidine will take care both high bp and withdrawal

11. 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
Coronary artery disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

12. Should we tx htn in acute ischemic stroke

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13. When to suspect traumatic LP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
RBC count >6000
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

14. Patient with carbamazepine; What should be advice?
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
82% specific for dementia

15. infections in GBS
Femoral n lesion
Acetylecholinersterase inhibitors
Autospy gold standard
EPV - campylobacter - HSV

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

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17. at first tingling in toes and feet then weakness in extremities
Cholinesterase inhibitor; and antiparkinsonism drugs
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
90% of right handed and 60% of left handed persons; speech and language function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

18. cluster headache
Acetylecholinersterase inhibitors
EPV - campylobacter - HSV
Propranolol or primidone
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

19. dominant parietal lobe on the left side
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Botulism has descending paralysis in contrast othere have ascending paralysis
90% of right handed and 60% of left handed persons; speech and language function

20. severe headache and high BP
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
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;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

21. MG
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Deficit in cranial nerve function
Acetylecholinersterase inhibitors
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

22. When to use brain spect scintigraphy to confirm brain death
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
It patient has electrolyte imbalance and hypothermia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Get up from chair walk a short distance turn around and sit; screening test for fall

23. How to differentiate traumatic LP and SAH
Autospy gold standard
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

24. medial thigh sensory loss and weakness in addcution
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Obturator n lesion

25. botulism
Diabetes insipidus
Obturator n lesion
Antitoxin
Wernicke's encephalopathy; due to thiamine definition; medical emergency

26. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
RBC count >6000

27. double vision at the end of day and ptosis
Construction apraxia; lesion in non dominant parietal lobe (right)
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write
Myasthenia; due to autoantibodies against acetylecholine receptor;

28. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
82% specific for dementia
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
Cerebral palsy; dx mri

29. labyrinthitis
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

30. indication of plasmapheresis in GBS
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
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

31. What mmse score suggest dementia
Propranolol or primidone
<20; if patient scores >25 benign forgetfulness
Myasthenia; due to autoantibodies against acetylecholine receptor;
Diabetes insipidus

32. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Distal lower motor neuron disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

33. When headache is presenting complaint of brain tumor
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Cerebral palsy; dx mri

34. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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;
Autospy gold standard

35. How to prevent prevent frequency of MS exacerbation
Diabetes insipidus
90% of right handed and 60% of left handed persons; speech and language function
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
It patient has electrolyte imbalance and hypothermia

36. craniopharyngioma
Not within 24 hours; give afte 24-48 hours if patient stable
IVIG and plasmapheresis
Diabetes insipidus
Reduced efficacy of OCP

37. impaired vibration and increased DTR
Myasthenia; due to autoantibodies against acetylecholine receptor;
Vitamin B12 deficiency
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
90% of right handed and 60% of left handed persons; speech and language function

38. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Normal pressure hydrocephalus
Autospy gold standard
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

39. impaired hepatic conjugation of billirubin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Gilberts disease
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

40. cortical lesion
Lesion in nondominant temporal lobe
Autospy gold standard
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aphasia - neglect - agnosia - acalculia etc

41. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

42. differentiate lewy body dementia and vascular dementia
Reduced efficacy of OCP
MS
Entacapone - COMT inhibitor
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

43. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Antitoxin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

44. prodrome of vasovagal syncope
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
Cerebral palsy; dx mri
Tunnel vision - diaphoresis - nausea - pallor

45. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal
82% specific for dementia

46. What is can be used cluster headache prevention
Verapamil
Corticosteroid and acyclovir
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

47. What is pronator drift
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

48. differentiate wenicke and korsakoff
Clonidine will take care both high bp and withdrawal
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
Spastic paraparesis
Aspirin - control HTN and swallow eval before giving any oral meds

49. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
IVIG and plasmapheresis
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
Cerebral palsy; dx mri

50. acoustic neuroma
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
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
Autospy gold standard

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USMLE Step3 Neurology

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