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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. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Normal pressure hydrocephalus
Clonidine will take care both high bp and withdrawal
MS

2. When to use dopamine agonist pramipexol in parkinson
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

3. impaired vibration and increased DTR
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency
Wernicke's encephalopathy; due to thiamine definition; medical emergency

4. How to tx acute exacerbation of MS
20%
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
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
High dose IV methyleprednisone;

5. How to manage stroke patient came within 4 hours
Deficit in cranial nerve function
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

6. 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
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.
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

7. phenytoin and OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Difficulty in writing - calculating - distinguishing left and write
Reduced efficacy of OCP
Acetylecholinersterase inhibitors

8. How to differentiate medial and lateral pontine syndrome
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

9. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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.
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds

10. How to confirm braindeath?
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Autospy gold standard

11. How to differentiate medial and lateral medullary syndrome
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
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;
Lesion in nondominant temporal lobe
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

12. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Upright supine position
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

13. impaired perception of complex sounds
<20; if patient scores >25 benign forgetfulness
Despite the term neuroma they arise from schwann cells - schwanoma
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Lesion in nondominant temporal lobe

14. When headache is presenting complaint of brain tumor
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Femoral n lesion

15. contraindication of sumatripta
Femoral n lesion
Corticosteroid and acyclovir
RBC count >6000
Coronary artery disease

16. lesion in dominant parietal lobe
Not within 24 hours; give afte 24-48 hours if patient stable
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Difficulty in writing - calculating - distinguishing left and write
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

17. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Verapamil
EPV - campylobacter - HSV

18. MMSE score of less than 24
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
82% specific for dementia

19. When to suspect traumatic LP
Not within 24 hours; give afte 24-48 hours if patient stable
RBC count >6000
Propranolol or primidone
Nystagmus on far lateral gaze

20. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Spastic paraparesis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Taper gradually to prevent seizure relapse

21. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Deficit in cranial nerve function
Taper gradually to prevent seizure relapse
High dose IV methyleprednisone;

22. Should we tx htn in acute ischemic stroke

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23. How to tx lewy body dementia
Verapamil
Normal pressure hydrocephalus
Tunnel vision - diaphoresis - nausea - pallor
Cholinesterase inhibitor; and antiparkinsonism drugs

24. dementia plus urinary incontinence
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Normal pressure hydrocephalus

25. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Diabetes insipidus
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
IVIG and plasmapheresis
RBC count >6000

26. at first tingling in toes and feet then weakness in extremities
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

27. benign essential tremor
Propranolol or primidone
Deficit in cranial nerve function
Not within 24 hours; give afte 24-48 hours if patient stable
<20; if patient scores >25 benign forgetfulness

28. get up and go test
Lesion in nondominant temporal lobe
Get up from chair walk a short distance turn around and sit; screening test for fall
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
82% specific for dementia

29. cluster headache
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

30. 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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

31. indication of plasmapheresis in GBS
RBC count >6000
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

32. What is pronator drift
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Botulism has descending paralysis in contrast othere have ascending paralysis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

33. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Reduced efficacy of OCP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tunnel vision - diaphoresis - nausea - pallor

34. How to differentiate parkinson and benign essential tremor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
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
MS

35. severe headache and high BP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Botulism has descending paralysis in contrast othere have ascending paralysis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

36. differentiate lewy body dementia and vascular dementia
Cerebellar lesion
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
Reduced efficacy of OCP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

37. How to tx stroke patient came after 6h
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Aspirin - control HTN and swallow eval before giving any oral meds

38. What mmse score suggest dementia
High dose IV methyleprednisone;
<20; if patient scores >25 benign forgetfulness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion

39. How to differentiate traumatic LP and SAH
Diabetes insipidus
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
IVIG and plasmapheresis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

40. impaired hepatic conjugation of billirubin
Clonidine will take care both high bp and withdrawal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Gilberts disease

41. brain stem lesion
Aspirin - control HTN and swallow eval before giving any oral meds
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
Deficit in cranial nerve function
EPV - campylobacter - HSV

42. differentiate wenicke and korsakoff
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Reduced efficacy of OCP
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
90% of right handed and 60% of left handed persons; speech and language function

43. craniopharyngioma
Nystagmus on far lateral gaze
Diabetes insipidus
82% specific for dementia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

44. korsafoff psychosis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

45. cortical lesion
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.
Aphasia - neglect - agnosia - acalculia etc
Obturator n lesion
Cerebral palsy; dx mri

46. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spastic paraparesis

47. 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
Upright supine position
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

48. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Distal lower motor neuron disease
Entacapone - COMT inhibitor
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

49. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
EPV - campylobacter - HSV
Coronary artery disease
Get up from chair walk a short distance turn around and sit; screening test for fall

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

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USMLE Step3 Neurology

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