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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. How to prevent prevent frequency of MS exacerbation
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

2. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency
Reduced efficacy of OCP
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

3. earliest sign of phenytoin toxicity
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Nystagmus on far lateral gaze
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable

4. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Upright supine position
Corticosteroid and acyclovir
Normal pressure hydrocephalus

5. When to suspect traumatic LP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Construction apraxia; lesion in non dominant parietal lobe (right)
RBC count >6000
Antitoxin

6. medial thigh sensory loss and weakness in addcution
Verapamil
20%
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Obturator n lesion

7. Why V12 deficient develop hypokalemia after tx with b12
Deficit in cranial nerve function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

8. infections in GBS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
EPV - campylobacter - HSV
Vitamin B12 deficiency

9. phenytoin and OCP
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
Verapamil
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

10. contraindication of sumatripta
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Coronary artery disease

11. When headache is presenting complaint of brain tumor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Gilberts disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

12. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Obturator n lesion
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

13. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Verapamil
Deficit in cranial nerve function
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

14. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Reduced efficacy of OCP
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

15. best diagnosis for parkinsonim
Acetylecholinersterase inhibitors
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Autospy gold standard

16. prodrome of vasovagal syncope
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
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
Despite the term neuroma they arise from schwann cells - schwanoma

17. Tx of bells palsy
Coronary artery disease
Corticosteroid and acyclovir
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Taper gradually to prevent seizure relapse

18. How to tx stroke patient came after 6h
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
Antitoxin
Clonidine will take care both high bp and withdrawal

19. How to differentiate traumatic LP and SAH
Lesion in nondominant temporal lobe
Autospy gold standard
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

20. impaired perception of complex sounds
Acetylecholinersterase inhibitors
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

21. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

22. labyrinthitis
High dose IV methyleprednisone;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Nystagmus on far lateral gaze
Follows viral illness; vertigo - tinnitus - nausea. self limiting

23. botulism
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Antitoxin
Cerebellar lesion

24. stroke with lower facial palsy - pronator drift despite on aspirin
Clonidine will take care both high bp and withdrawal
Construction apraxia; lesion in non dominant parietal lobe (right)
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

25. indication of plasmapheresis in GBS
Myasthenia; due to autoantibodies against acetylecholine receptor;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Reduced efficacy of OCP
Despite the term neuroma they arise from schwann cells - schwanoma

26. excessive elevation of legs during walking (toe touch floor earlier than heels)
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
EPV - campylobacter - HSV
Distal lower motor neuron 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

27. When to use dopamine agonist pramipexol in parkinson
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Construction apraxia; lesion in non dominant parietal lobe (right)
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

28. double vision at the end of day and ptosis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Propranolol or primidone
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Myasthenia; due to autoantibodies against acetylecholine receptor;

29. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Wernicke's encephalopathy; due to thiamine definition; medical emergency

30. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Lesion in nondominant temporal lobe
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
Coronary artery disease

31. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
IVIG and plasmapheresis
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
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

32. craniopharyngioma
Cerebral palsy; dx mri
Diabetes insipidus
Not within 24 hours; give afte 24-48 hours if patient stable
Cholinesterase inhibitor; and antiparkinsonism drugs

33. What is pronator drift
Propranolol or primidone
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV
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

34. differentiate lewy body dementia and vascular dementia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
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
Get up from chair walk a short distance turn around and sit; screening test for fall

35. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Upright supine position
IVIG and plasmapheresis
Entacapone - COMT inhibitor

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

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37. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Obturator n lesion
Botulism has descending paralysis in contrast othere have ascending paralysis
Normal pressure hydrocephalus

38. acoustic neuroma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Despite the term neuroma they arise from schwann cells - schwanoma
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

39. 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
Aphasia - neglect - agnosia - acalculia etc
Vitamin B12 deficiency
Despite the term neuroma they arise from schwann cells - schwanoma

40. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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 glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

41. GBS
IVIG and plasmapheresis
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

42. How to differentiate medial and lateral pontine syndrome
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Not within 24 hours; give afte 24-48 hours if patient stable
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

43. dominant parietal lobe on the left side
Verapamil
Reduced efficacy of OCP
Botulism has descending paralysis in contrast othere have ascending paralysis
90% of right handed and 60% of left handed persons; speech and language function

44. Should we tx htn in acute ischemic stroke

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45. How to differentiate parkinson and benign essential tremor
20%
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
Spastic paraparesis
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.

46. How to differentiate medial and lateral medullary syndrome
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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;
Propranolol or primidone
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

47. lesion in dominant parietal lobe
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Difficulty in writing - calculating - distinguishing left and write
Reduced efficacy of OCP
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

48. How to tx acute exacerbation of MS
Lesion in nondominant temporal lobe
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
High dose IV methyleprednisone;
Deficit in cranial nerve function

49. MMSE score of less than 24
82% specific for dementia
<20; if patient scores >25 benign forgetfulness
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

50. 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
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

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USMLE Step3 Neurology

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