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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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
Distal lower motor neuron disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

2. anerior and anteriomedial thigh paresthesia - decreased DTR
Antitoxin
Femoral n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Gilberts disease

3. acoustic neuroma
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS

4. at first tingling in toes and feet then weakness in extremities
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Coronary artery disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

5. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Obturator 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

6. When to start fibrinolytic therapy in stroke patient?
MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Autospy gold standard
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

7. How to differentiate medial and lateral pontine syndrome
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
Corticosteroid and acyclovir
Clonidine will take care both high bp and withdrawal
Upright supine position

8. How to manage stroke patient came within 4 hours
IVIG and plasmapheresis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

9. How to differentiate medial and lateral medullary syndrome
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Not within 24 hours; give afte 24-48 hours if patient stable
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;

10. brain stem lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
Deficit in cranial nerve function
High dose IV methyleprednisone;

11. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebellar lesion
Normal pressure hydrocephalus
Coronary artery disease

12. korsafoff psychosis
Corticosteroid and acyclovir
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

13. Should we tx htn in acute ischemic stroke

14. dominant parietal lobe on the left side
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
90% of right handed and 60% of left handed persons; speech and language function
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Myasthenia; due to autoantibodies against acetylecholine receptor;

15. When to give aspirin when patient on tPA after stroke
Spontaneous remission; admit if suspected and monitor pulse ox for 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
Not within 24 hours; give afte 24-48 hours if patient stable
Construction apraxia; lesion in non dominant parietal lobe (right)

16. lesion in dominant tempora lobe
Botulism has descending paralysis in contrast othere have ascending paralysis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

17. Why V12 deficient develop hypokalemia after tx with b12
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
Cerebellar lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

18. impaired perception of complex sounds
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS
Cholinesterase inhibitor; and antiparkinsonism drugs
Lesion in nondominant temporal lobe

19. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
IVIG and plasmapheresis
Deficit in cranial nerve function
Clonidine will take care both high bp and withdrawal
Spastic paraparesis

20. prodrome of vasovagal syncope
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Tunnel vision - diaphoresis - nausea - pallor
Not within 24 hours; give afte 24-48 hours if patient stable
Entacapone - COMT inhibitor

21. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Myasthenia; due to autoantibodies against acetylecholine receptor;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Verapamil
Upright supine position

22. lesion in dominant parietal lobe
82% specific for dementia
Difficulty in writing - calculating - distinguishing left and write
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

23. excessive elevation of legs during walking (toe touch floor earlier than heels)
Upright supine position
MS
Distal lower motor neuron disease
Taper gradually to prevent seizure relapse

24. What is pronator drift
Nystagmus on far lateral gaze
Not within 24 hours; give afte 24-48 hours if patient stable
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
Acetylecholinersterase inhibitors

25. What percent of dementia is reversible
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
20%
RBC count >6000
Obturator n lesion

26. What mmse score suggest dementia
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
Aphasia - neglect - agnosia - acalculia etc
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
<20; if patient scores >25 benign forgetfulness

27. When to suspect traumatic LP
RBC count >6000
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cholinesterase inhibitor; and antiparkinsonism drugs

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

29. oligoclonal band in CSF
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Propranolol or primidone
Aphasia - neglect - agnosia - acalculia etc
MS

30. How to differentiate traumatic LP and SAH
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin

31. cortical lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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.
Coronary artery disease
Aphasia - neglect - agnosia - acalculia etc

32. infections in GBS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
EPV - campylobacter - HSV
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position

33. 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
Nystagmus on far lateral gaze
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Antitoxin

34. What is can be used cluster headache prevention
Verapamil
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

35. When headache is presenting complaint of brain tumor
Lesion in nondominant temporal lobe
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
90% of right handed and 60% of left handed persons; speech and language function

36. labyrinthitis
Spastic paraparesis
Nystagmus on far lateral gaze
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

37. impaired hepatic conjugation of billirubin
Cerebral palsy; dx mri
Despite the term neuroma they arise from schwann cells - schwanoma
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Gilberts disease

38. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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

39. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

40. women with unilateral eye pain; neurlogic symptoms here there at different times
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in writing - calculating - distinguishing left and write
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

41. medial thigh sensory loss and weakness in addcution
Femoral n lesion
It patient has electrolyte imbalance and hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Obturator n lesion

42. How to tx lewy body dementia
Distal lower motor neuron disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Coronary artery disease
Cholinesterase inhibitor; and antiparkinsonism drugs

43. 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
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
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
MS

44. botulism
Antitoxin
EPV - campylobacter - HSV
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
Reduced efficacy of OCP

45. MG
Spastic paraparesis
Acetylecholinersterase inhibitors
High dose IV methyleprednisone;
90% of right handed and 60% of left handed persons; speech and language function

46. contraindication of sumatripta
Despite the term neuroma they arise from schwann cells - schwanoma
90% of right handed and 60% of left handed persons; speech and language function
Coronary artery disease
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

47. How to stop antiepileptic drugs
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Taper gradually to prevent seizure relapse
Antitoxin

48. How to differentiate botulism from tick born paralysis - GBS and MG
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Verapamil
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Botulism has descending paralysis in contrast othere have ascending paralysis

49. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Nystagmus on far lateral gaze
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Femoral n lesion

50. differentiate lewy body dementia and vascular dementia
RBC count >6000
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
Corticosteroid and acyclovir
High dose IV methyleprednisone;