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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. What is pronator drift
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Clonidine will take care both high bp and withdrawal

2. How to tx lewy body dementia
Difficulty in writing - calculating - distinguishing left and write
Cholinesterase inhibitor; and antiparkinsonism drugs
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Obturator n lesion

3. cortical lesion
MS
Femoral n lesion
Spastic paraparesis
Aphasia - neglect - agnosia - acalculia etc

4. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Aphasia - neglect - agnosia - acalculia etc
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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;

5. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Cerebral palsy; dx mri
Myasthenia; due to autoantibodies against acetylecholine receptor;

6. MG
Construction apraxia; lesion in non dominant parietal lobe (right)
Acetylecholinersterase inhibitors
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

7. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
Cerebellar lesion
Verapamil

8. What percent of dementia is reversible
Cholinesterase inhibitor; and antiparkinsonism drugs
20%
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

9. 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
Vitamin B12 deficiency
MS
Corticosteroid and acyclovir

10. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
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
Spastic paraparesis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

11. botulism
Aspirin - control HTN and swallow eval before giving any oral meds
Antitoxin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

12. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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
Cerebellar lesion
Spastic paraparesis

13. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis
It patient has electrolyte imbalance and hypothermia

14. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Antitoxin
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;
Wernicke's encephalopathy; due to thiamine definition; medical emergency

15. Patient with carbamazepine; What should be advice?
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Cerebral palsy; dx mri
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

16. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

17. How to differentiate medial and lateral pontine syndrome
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Diabetes insipidus
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
Gilberts disease

18. How to tx acute exacerbation of MS
Cerebral palsy; dx mri
Cholinesterase inhibitor; and antiparkinsonism drugs
High dose IV methyleprednisone;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

19. How to differentiate parkinson and benign essential tremor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Femoral n lesion

20. contraindication of sumatripta
Coronary artery disease
Vitamin B12 deficiency
Deficit in cranial nerve function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

21. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

22. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Get up from chair walk a short distance turn around and sit; screening test for fall
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Entacapone - COMT inhibitor

23. 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

24. When headache is presenting complaint of brain tumor
Distal lower motor neuron disease
Entacapone - COMT inhibitor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

25. dementia plus urinary incontinence
EPV - campylobacter - HSV
It patient has electrolyte imbalance and hypothermia
Aphasia - neglect - agnosia - acalculia etc
Normal pressure hydrocephalus

26. 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
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

27. Should we tx htn in acute ischemic stroke

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28. How to perform apnea test
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
Obturator n lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Normal pressure hydrocephalus

29. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Gilberts disease
Autospy gold standard
Upright supine position

30. best diagnosis for parkinsonim
Autospy gold standard
<20; if patient scores >25 benign forgetfulness
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;

31. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

32. earliest sign of phenytoin toxicity
Despite the term neuroma they arise from schwann cells - schwanoma
20%
Nystagmus on far lateral gaze
Femoral n lesion

33. what drug is used to extend effects of levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Entacapone - COMT inhibitor
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
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;

34. medial thigh sensory loss and weakness in addcution
Spastic paraparesis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Obturator n lesion
Propranolol or primidone

35. double vision at the end of day and ptosis
It patient has electrolyte imbalance and hypothermia
Myasthenia; due to autoantibodies against acetylecholine receptor;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

36. How to prevent prevent frequency of MS exacerbation
Propranolol or primidone
Not within 24 hours; give afte 24-48 hours if patient stable
Aphasia - neglect - agnosia - acalculia etc
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

37. Blood transfusion in hypothermia
Gilberts disease
<20; if patient scores >25 benign forgetfulness
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Reduced efficacy of OCP

38. 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
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.
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

39. Tx of GBS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease

40. cluster headache
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Obturator n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

41. indication of plasmapheresis in GBS
Get up from chair walk a short distance turn around and sit; screening test for fall
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
It patient has electrolyte imbalance and hypothermia

42. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Construction apraxia; lesion in non dominant parietal lobe (right)
It patient has electrolyte imbalance and hypothermia
RBC count >6000

43. excessive elevation of legs during walking (toe touch floor earlier than heels)
Diabetes insipidus
Distal lower motor neuron disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Taper gradually to prevent seizure relapse

44. differentiate wenicke and korsakoff
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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. Unable to copy of matchstick - unable to dress up
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
Cerebral palsy; dx mri
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Construction apraxia; lesion in non dominant parietal lobe (right)

46. When to suspect traumatic LP
Distal lower motor neuron disease
RBC count >6000
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;

47. benign essential tremor
It patient has electrolyte imbalance and hypothermia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Propranolol or primidone

48. phenytoin and OCP
Deficit in cranial nerve function
Reduced efficacy of OCP
Verapamil
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

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

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50. differentiate picks and huntington
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
Diabetes insipidus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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