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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. Should we tx htn in acute ischemic stroke

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2. differentiate picks and huntington
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
Acetylecholinersterase inhibitors
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spastic paraparesis

3. How to manage stroke patient came within 4 hours
Diabetes insipidus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

4. When to suspect traumatic LP
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
RBC count >6000
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

5. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Femoral n lesion
Upright supine position
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

6. differentiate lewy body dementia and vascular dementia
Difficulty in writing - calculating - distinguishing left and write
Corticosteroid and acyclovir
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

7. How to prevent prevent frequency of MS exacerbation
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

8. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Botulism has descending paralysis in contrast othere have ascending paralysis

9. oligoclonal band in CSF
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
<20; if patient scores >25 benign forgetfulness
MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

10. What is can be used cluster headache prevention
Spastic paraparesis
Obturator n lesion
Verapamil
Propranolol or primidone

11. excessive elevation of legs during walking (toe touch floor earlier than heels)
Aspirin - control HTN and swallow eval before giving any oral meds
EPV - campylobacter - HSV
Deficit in cranial nerve function
Distal lower motor neuron disease

12. How to differentiate botulism from tick born paralysis - GBS and MG
Deficit in cranial nerve function
Vitamin B12 deficiency
Difficulty in writing - calculating - distinguishing left and write
Botulism has descending paralysis in contrast othere have ascending paralysis

13. craniopharyngioma
Diabetes insipidus
Tunnel vision - diaphoresis - nausea - pallor
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
RBC count >6000

14. impaired vibration and increased DTR
Not within 24 hours; give afte 24-48 hours if patient stable
Vitamin B12 deficiency
Autospy gold standard
Antitoxin

15. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
IVIG and plasmapheresis

16. indication of plasmapheresis in GBS
Cerebral palsy; dx mri
Acetylecholinersterase inhibitors
Coronary artery disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

17. contraindication of sumatripta
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Corticosteroid and acyclovir
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
Coronary artery disease

18. earliest sign of phenytoin toxicity
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus
Nystagmus on far lateral gaze

19. best diagnosis for parkinsonim
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Autospy gold standard

20. get up and go test
<20; if patient scores >25 benign forgetfulness
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Vitamin B12 deficiency
Get up from chair walk a short distance turn around and sit; screening test for fall

21. How to differentiate medial and lateral pontine syndrome
MS
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;
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

22. What mmse score suggest dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
<20; if patient scores >25 benign forgetfulness
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

23. phenytoin and OCP
Reduced efficacy of OCP
Myasthenia; due to autoantibodies against acetylecholine receptor;
<20; if patient scores >25 benign forgetfulness
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

24. korsafoff psychosis
Autospy gold standard
Corticosteroid and acyclovir
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
High dose IV methyleprednisone;

25. Unable to copy of matchstick - unable to dress up
Reduced efficacy of OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Construction apraxia; lesion in non dominant parietal lobe (right)

26. acoustic neuroma
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Despite the term neuroma they arise from schwann cells - schwanoma
Gilberts disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

27. benign essential tremor
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
<20; if patient scores >25 benign forgetfulness
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Propranolol or primidone

28. 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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Antitoxin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

29. What is pronator drift
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.
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Lesion in nondominant temporal lobe

30. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

31. MMSE score of less than 24
20%
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia
Spastic paraparesis

32. severe headache and high BP
Verapamil
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

33. How to confirm braindeath?
Get up from chair walk a short distance turn around and sit; screening test for fall
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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.
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

34. dementia plus urinary incontinence
Normal pressure hydrocephalus
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
High dose IV methyleprednisone;

35. What percent of dementia is reversible
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
20%

36. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Nystagmus on far lateral gaze

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

38. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
IVIG and plasmapheresis
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

39. impaired hepatic conjugation of billirubin
Gilberts disease
Lesion in nondominant temporal lobe
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Not within 24 hours; give afte 24-48 hours if patient stable

40. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Aphasia - neglect - agnosia - acalculia etc
Vitamin B12 deficiency
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Clonidine will take care both high bp and withdrawal

41. Patient with carbamazepine; What should be advice?
Aphasia - neglect - agnosia - acalculia etc
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Propranolol or primidone

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

43. GBS
<20; if patient scores >25 benign forgetfulness
IVIG and plasmapheresis
Normal pressure hydrocephalus
Cholinesterase inhibitor; and antiparkinsonism drugs

44. stroke with lower facial palsy - pronator drift despite on aspirin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
<20; if patient scores >25 benign forgetfulness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse

45. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Spastic paraparesis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Obturator n lesion

46. Why V12 deficient develop hypokalemia after tx with b12
Nystagmus on far lateral gaze
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Autospy gold standard
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

47. MG
Acetylecholinersterase inhibitors
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Coronary artery disease

48. Acute onset of left arm weakness
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
90% of right handed and 60% of left handed persons; speech and language function
IVIG and plasmapheresis

49. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebral palsy; dx mri
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
<20; if patient scores >25 benign forgetfulness

50. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
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.

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USMLE Step3 Neurology

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