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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. benign essential tremor
Obturator n lesion
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
Propranolol or primidone
Aphasia - neglect - agnosia - acalculia etc

2. differentiate picks and huntington
Gilberts disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

3. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Propranolol or primidone

4. anerior and anteriomedial thigh paresthesia - decreased DTR
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
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Deficit in cranial nerve function

5. phenytoin and OCP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP
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
Coronary artery disease

6. How to tx lewy body dementia
Autospy gold standard
Cholinesterase inhibitor; and antiparkinsonism drugs
Corticosteroid and acyclovir
Entacapone - COMT inhibitor

7. When to suspect traumatic LP
RBC count >6000
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Clonidine will take care both high bp and withdrawal
Aphasia - neglect - agnosia - acalculia etc

8. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
Normal pressure hydrocephalus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

9. When headache is presenting complaint of brain tumor
Not within 24 hours; give afte 24-48 hours if patient stable
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

10. How to differentiate medial and lateral medullary syndrome
90% of right handed and 60% of left handed persons; speech and language function
Corticosteroid and acyclovir
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;
Obturator n lesion

11. When to use brain spect scintigraphy to confirm brain death
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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.
20%
It patient has electrolyte imbalance and hypothermia

12. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Entacapone - COMT inhibitor
Gilberts disease
Wernicke's encephalopathy; due to thiamine definition; medical emergency

13. Should we tx htn in acute ischemic stroke

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14. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Verapamil
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

15. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease
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
EPV - campylobacter - HSV

16. lesion in dominant parietal lobe
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in writing - calculating - distinguishing left and write
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

17. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion

18. Acute onset of left arm weakness
Cerebral palsy; dx mri
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
82% specific for dementia

19. impaired vibration and increased DTR
Vitamin B12 deficiency
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.
Obturator n lesion
Clonidine will take care both high bp and withdrawal

20. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
IVIG and plasmapheresis
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.
Diabetes insipidus
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

21. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Gilberts disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Obturator n lesion

22. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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;

23. differentiate lewy body dementia and vascular dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Lesion in nondominant temporal lobe
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

24. Tx of bells palsy
90% of right handed and 60% of left handed persons; speech and language function
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
Corticosteroid and acyclovir

25. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
EPV - campylobacter - HSV
Entacapone - COMT inhibitor
Clonidine will take care both high bp and withdrawal

26. excessive elevation of legs during walking (toe touch floor earlier than heels)
Normal pressure hydrocephalus
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.
EPV - campylobacter - HSV
Distal lower motor neuron disease

27. When to start fibrinolytic therapy in stroke patient?
Lesion in nondominant temporal lobe
Cerebellar lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Femoral n lesion

28. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts disease
Entacapone - COMT inhibitor
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

29. GBS
IVIG and plasmapheresis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Entacapone - COMT inhibitor

30. indication of plasmapheresis in GBS
IVIG and plasmapheresis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard
Tunnel vision - diaphoresis - nausea - pallor

31. impaired hepatic conjugation of billirubin
Gilberts disease
Normal pressure hydrocephalus
MS: CSF increased IgG -IgM and IgA also increased. not specific to 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

32. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cerebral palsy; dx mri
Taper gradually to prevent seizure relapse

33. How to prevent prevent frequency of MS exacerbation
Vitamin B12 deficiency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

34. botulism
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Antitoxin
<20; if patient scores >25 benign forgetfulness
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

35. Tx of GBS
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Femoral n lesion
Difficulty in writing - calculating - distinguishing left and write

36. Unable to copy of matchstick - unable to dress up
High dose IV methyleprednisone;
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
Propranolol or primidone
Construction apraxia; lesion in non dominant parietal lobe (right)

37. dementia plus urinary incontinence
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Normal pressure hydrocephalus
High dose IV methyleprednisone;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

38. brain stem lesion
Acetylecholinersterase inhibitors
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Distal lower motor neuron disease
Deficit in cranial nerve function

39. 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
<20; if patient scores >25 benign forgetfulness
Antitoxin
Diabetes insipidus

40. 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
90% of right handed and 60% of left handed persons; speech and language function
Vitamin B12 deficiency
Tunnel vision - diaphoresis - nausea - pallor

41. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Construction apraxia; lesion in non dominant parietal lobe (right)
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

42. Patient with carbamazepine; What should be advice?
Corticosteroid and acyclovir
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;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

43. best diagnosis for parkinsonim
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Autospy gold standard
Get up from chair walk a short distance turn around and sit; screening test for fall
Tunnel vision - diaphoresis - nausea - pallor

44. How to differentiate dementias
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Myasthenia; due to autoantibodies against acetylecholine receptor;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

45. infections in GBS
EPV - campylobacter - HSV
RBC count >6000
High dose IV methyleprednisone;
Cerebellar lesion

46. oligoclonal band in CSF
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS
<20; if patient scores >25 benign forgetfulness

47. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Myasthenia; due to autoantibodies against acetylecholine receptor;
MS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

48. MG
RBC count >6000
Acetylecholinersterase inhibitors
<20; if patient scores >25 benign forgetfulness
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

49. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
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
Not within 24 hours; give afte 24-48 hours if patient stable
Lesion in nondominant temporal lobe

50. MMSE score of less than 24
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Verapamil
Femoral n lesion
82% specific for dementia

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USMLE Step3 Neurology

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