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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. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Despite the term neuroma they arise from schwann cells - schwanoma
Acetylecholinersterase inhibitors
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

2. What is pronator drift
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Entacapone - COMT inhibitor
Myasthenia; due to autoantibodies against acetylecholine receptor;

3. How to manage stroke patient came within 4 hours
Vitamin B12 deficiency
Cerebellar lesion
Taper gradually to prevent seizure relapse
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

4. korsafoff psychosis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Aspirin - control HTN and swallow eval before giving any oral meds

5. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
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.
IVIG and plasmapheresis

6. contraindication of sumatripta
Not within 24 hours; give afte 24-48 hours if patient stable
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Coronary artery disease
Aphasia - neglect - agnosia - acalculia etc

7. How to tx stroke patient came after 6h
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aspirin - control HTN and swallow eval before giving any oral meds
Get up from chair walk a short distance turn around and sit; screening test for fall
High dose IV methyleprednisone;

8. differentiate lewy body dementia and vascular dementia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Construction apraxia; lesion in non dominant parietal lobe (right)
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

9. cluster headache
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
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
IVIG and plasmapheresis

10. lesion in dominant tempora lobe
Spastic paraparesis
IVIG and plasmapheresis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

11. When to suspect traumatic LP
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
Spastic paraparesis
Coronary artery disease
RBC count >6000

12. What is can be used cluster headache prevention
Difficulty in writing - calculating - distinguishing left and write
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Verapamil

13. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
It patient has electrolyte imbalance and hypothermia
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
Botulism has descending paralysis in contrast othere have ascending paralysis

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

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15. oligoclonal band in CSF
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
MS
Taper gradually to prevent seizure relapse

16. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
90% of right handed and 60% of left handed persons; speech and language function
Clonidine will take care both high bp and withdrawal

17. acoustic neuroma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Despite the term neuroma they arise from schwann cells - schwanoma
Get up from chair walk a short distance turn around and sit; screening test for fall
It patient has electrolyte imbalance and hypothermia

18. 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
Deficit in cranial nerve function
<20; if patient scores >25 benign forgetfulness
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

19. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
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
90% of right handed and 60% of left handed persons; speech and language function

20. craniopharyngioma
RBC count >6000
Diabetes insipidus
Aspirin - control HTN and swallow eval before giving any oral meds
Verapamil

21. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

22. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Construction apraxia; lesion in non dominant parietal lobe (right)

23. When to give aspirin when patient on tPA after stroke
Construction apraxia; lesion in non dominant parietal lobe (right)
Reduced efficacy of OCP
Tunnel vision - diaphoresis - nausea - pallor
Not within 24 hours; give afte 24-48 hours if patient stable

24. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
EPV - campylobacter - HSV
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
It patient has electrolyte imbalance and hypothermia

25. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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.
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

26. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebellar lesion
Propranolol or primidone
Reduced efficacy of OCP

27. Acute onset of left arm weakness
Lesion in nondominant temporal lobe
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
EPV - campylobacter - HSV

28. Why V12 deficient develop hypokalemia after tx with b12
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

29. botulism
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Antitoxin
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
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

30. impaired hepatic conjugation of billirubin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Gilberts disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Deficit in cranial nerve function

31. brain stem lesion
Nystagmus on far lateral gaze
Clonidine will take care both high bp and withdrawal
20%
Deficit in cranial nerve function

32. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Not within 24 hours; give afte 24-48 hours if patient stable
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Aphasia - neglect - agnosia - acalculia etc

33. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Coronary artery disease

34. differentiate picks and huntington
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
20%
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

35. Blood transfusion in hypothermia
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Deficit in cranial nerve function
MS

36. How to differentiate traumatic LP and SAH
Tunnel vision - diaphoresis - nausea - pallor
Deficit in cranial nerve function
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

37. severe headache and high BP
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

38. double vision at the end of day and ptosis
Normal pressure hydrocephalus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Autospy gold standard
Myasthenia; due to autoantibodies against acetylecholine receptor;

39. anerior and anteriomedial thigh paresthesia - decreased DTR
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Femoral n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

40. How to confirm braindeath?
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.
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
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
Femoral n lesion

41. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

42. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

43. impaired vibration and increased DTR
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Vitamin B12 deficiency

44. Should we tx htn in acute ischemic stroke

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45. GBS
IVIG and plasmapheresis
Verapamil
High dose IV methyleprednisone;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

46. When headache is presenting complaint of brain tumor
Taper gradually to prevent seizure relapse
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Not within 24 hours; give afte 24-48 hours if patient stable

47. benign essential tremor
Propranolol or primidone
Deficit in cranial nerve function
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
90% of right handed and 60% of left handed persons; speech and language function

48. How to differentiate botulism from tick born paralysis - GBS and MG
Vitamin B12 deficiency
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Botulism has descending paralysis in contrast othere have ascending paralysis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

49. MG
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia
Acetylecholinersterase inhibitors
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

50. Tx of GBS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure