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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. Should we tx htn in acute ischemic stroke

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2. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
20%
Cerebellar lesion

3. 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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Normal pressure hydrocephalus
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

4. botulism
Antitoxin
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;
Entacapone - COMT inhibitor

5. impaired perception of complex sounds
Femoral n lesion
Entacapone - COMT inhibitor
Diabetes insipidus
Lesion in nondominant temporal lobe

6. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Cerebral palsy; dx mri
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

7. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
EPV - campylobacter - HSV
Cerebellar lesion

8. stroke with lower facial palsy - pronator drift despite on aspirin
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

9. MMSE score of less than 24
82% specific for dementia
Deficit in cranial nerve function
Myasthenia; due to autoantibodies against acetylecholine receptor;
Aphasia - neglect - agnosia - acalculia etc

10. When to suspect traumatic LP
Coronary artery disease
Cerebellar lesion
RBC count >6000
Autospy gold standard

11. When to use dopamine agonist pramipexol in parkinson
Normal pressure hydrocephalus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebral palsy; dx mri

12. Unable to copy of matchstick - unable to dress up
It patient has electrolyte imbalance and hypothermia
Construction apraxia; lesion in non dominant parietal lobe (right)
Get up from chair walk a short distance turn around and sit; screening test for fall
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

13. severe headache and high BP
Antitoxin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Corticosteroid and acyclovir
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

14. lesion in dominant tempora lobe
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
Autospy gold standard
Femoral n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

15. Acute onset of left arm weakness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Vitamin B12 deficiency
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable

16. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in writing - calculating - distinguishing left and write
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

17. How to differentiate parkinson and benign essential tremor
Entacapone - COMT inhibitor
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
Cerebellar lesion
Antitoxin

18. medial thigh sensory loss and weakness in addcution
Cholinesterase inhibitor; and antiparkinsonism drugs
Obturator n lesion
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;
Corticosteroid and acyclovir

19. best diagnosis for parkinsonim
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Autospy gold standard
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

20. How to confirm braindeath?
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;
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
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.

21. craniopharyngioma
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus
Cholinesterase inhibitor; and antiparkinsonism drugs

22. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Propranolol or primidone
Lesion in nondominant temporal lobe
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

23. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
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
Propranolol or primidone

24. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Propranolol or primidone
IVIG and plasmapheresis
Femoral n lesion

25. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS
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

26. lesion in dominant parietal lobe
Distal lower motor neuron disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in writing - calculating - distinguishing left and write
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

27. What mmse score suggest dementia
Normal pressure hydrocephalus
Reduced efficacy of OCP
Femoral n lesion
<20; if patient scores >25 benign forgetfulness

28. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in writing - calculating - distinguishing left and write
Myasthenia; due to autoantibodies against acetylecholine receptor;
82% specific for dementia

29. oligoclonal band in CSF
MS
Gilberts disease
Obturator n lesion
Femoral n lesion

30. Blood transfusion in hypothermia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
Upright supine position

31. How to perform apnea test
Femoral n lesion
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
EPV - campylobacter - HSV

32. How to prevent prevent frequency of MS exacerbation
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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;
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

33. impaired vibration and increased DTR
Botulism has descending paralysis in contrast othere have ascending paralysis
Vitamin B12 deficiency
Cholinesterase inhibitor; and antiparkinsonism drugs
Taper gradually to prevent seizure relapse

34. contraindication of sumatripta
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;
Despite the term neuroma they arise from schwann cells - schwanoma
Coronary artery disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

35. what drug is used to extend effects of levodopa
High dose IV methyleprednisone;
Aspirin - control HTN and swallow eval before giving any oral meds
Entacapone - COMT inhibitor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

36. brain stem lesion
Antitoxin
Deficit in cranial nerve function
Construction apraxia; lesion in non dominant parietal lobe (right)
High dose IV methyleprednisone;

37. MG
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acetylecholinersterase inhibitors

38. What is pronator drift
Distal lower motor neuron 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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

39. at first tingling in toes and feet then weakness in extremities
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.
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Obturator n lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

40. How to manage stroke patient came within 4 hours
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.
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Cholinesterase inhibitor; and antiparkinsonism drugs
Clonidine will take care both high bp and withdrawal

41. infections in GBS
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
EPV - campylobacter - HSV
Gilberts disease
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

42. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Despite the term neuroma they arise from schwann cells - schwanoma
Upright supine position
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.
MS

43. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
82% specific for dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Spastic paraparesis
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

44. Tx of bells palsy
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Corticosteroid and acyclovir
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

45. dominant parietal lobe on the left side
Acetylecholinersterase inhibitors
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Wernicke's encephalopathy; due to thiamine definition; medical emergency
90% of right handed and 60% of left handed persons; speech and language function

46. When headache is presenting complaint of brain tumor
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Lesion in nondominant temporal lobe

47. differentiate lewy body dementia and vascular dementia
High dose IV methyleprednisone;
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
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.
Femoral n lesion

48. How to stop antiepileptic drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Taper gradually to prevent seizure relapse
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Autospy gold standard

49. When to give aspirin when patient on tPA after stroke
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Not within 24 hours; give afte 24-48 hours if patient stable
Antitoxin
Nystagmus on far lateral gaze

50. How to differentiate medial and lateral pontine syndrome
Aphasia - neglect - agnosia - acalculia etc
Coronary artery 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
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

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USMLE Step3 Neurology

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