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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. Patient with carbamazepine; What should be advice?
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

2. acoustic neuroma
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.
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000

3. brain stem lesion
Cerebral palsy; dx mri
Acetylecholinersterase inhibitors
Deficit in cranial nerve function
Vitamin B12 deficiency

4. 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
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

5. How to confirm braindeath?
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.
High dose IV methyleprednisone;
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

6. benign essential tremor
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
Propranolol or primidone
Clonidine will take care both high bp and withdrawal
Diabetes insipidus

7. dementia plus urinary incontinence
Normal pressure hydrocephalus
Cerebral palsy; dx mri
Deficit in cranial nerve function
Aspirin - control HTN and swallow eval before giving any oral meds

8. botulism
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Antitoxin
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%

9. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Aphasia - neglect - agnosia - acalculia etc
Upright supine position
Reduced efficacy of OCP
Spastic paraparesis

10. How to differentiate parkinson and benign essential tremor
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
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Clonidine will take care both high bp and withdrawal

11. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Upright supine position
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MS

12. What is can be used cluster headache prevention
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
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.
Corticosteroid and acyclovir
Verapamil

13. contraindication of sumatripta
It patient has electrolyte imbalance and hypothermia
Diabetes insipidus
Coronary artery disease
Despite the term neuroma they arise from schwann cells - schwanoma

14. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Get up from chair walk a short distance turn around and sit; screening test for fall
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Cerebral palsy; dx mri
Cerebellar lesion

15. Should we tx htn in acute ischemic stroke

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16. stroke with lower facial palsy - pronator drift despite on aspirin
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Spastic paraparesis

17. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Cerebral palsy; dx mri
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Coronary artery disease

18. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Cerebellar lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

19. When headache is presenting complaint of brain tumor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Propranolol or primidone
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

20. get up and go test
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Not within 24 hours; give afte 24-48 hours if patient stable
Get up from chair walk a short distance turn around and sit; screening test for fall
Obturator n lesion

21. what drug is used to extend effects of levodopa
Cerebral palsy; dx mri
Entacapone - COMT inhibitor
Get up from chair walk a short distance turn around and sit; screening test for fall
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

22. labyrinthitis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Construction apraxia; lesion in non dominant parietal lobe (right)
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

23. lesion in dominant tempora lobe
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
Nystagmus on far lateral gaze

24. How to differentiate botulism from tick born paralysis - GBS and MG
Upright supine position
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis
Despite the term neuroma they arise from schwann cells - schwanoma

25. double vision at the end of day and ptosis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Diabetes insipidus
Myasthenia; due to autoantibodies against acetylecholine receptor;
Deficit in cranial nerve function

26. craniopharyngioma
Construction apraxia; lesion in non dominant parietal lobe (right)
Diabetes insipidus
Corticosteroid and acyclovir
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

27. How to differentiate medial and lateral pontine syndrome
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
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 glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

28. korsafoff psychosis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Corticosteroid and acyclovir
EPV - campylobacter - HSV
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

29. women with unilateral eye pain; neurlogic symptoms here there at different times
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Cerebellar lesion
Lesion in nondominant temporal lobe
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

30. How to differentiate medial and lateral medullary syndrome
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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;
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

31. How to tx lewy body dementia
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in writing - calculating - distinguishing left and write
Cholinesterase inhibitor; and antiparkinsonism drugs
Upright supine position

32. oligoclonal band in CSF
MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Verapamil

33. GBS
RBC count >6000
IVIG and plasmapheresis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Nystagmus on far lateral gaze

34. 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
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
Construction apraxia; lesion in non dominant parietal lobe (right)

35. How to differentiate dementias
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
82% specific for dementia

36. Unable to copy of matchstick - unable to dress up
Myasthenia; due to autoantibodies against acetylecholine receptor;
Construction apraxia; lesion in non dominant parietal lobe (right)
Entacapone - COMT inhibitor
IVIG and plasmapheresis

37. differentiate wenicke and korsakoff
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Lesion in nondominant temporal lobe
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

38. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Normal pressure hydrocephalus
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Clonidine will take care both high bp and withdrawal
Taper gradually to prevent seizure relapse

39. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spastic paraparesis
Get up from chair walk a short distance turn around and sit; screening test for fall

40. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Lesion in nondominant temporal lobe
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Diabetes insipidus

41. at first tingling in toes and feet then weakness in extremities
Myasthenia; due to autoantibodies against acetylecholine receptor;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Wernicke's encephalopathy; due to thiamine definition; medical emergency

42. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar 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;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Get up from chair walk a short distance turn around and sit; screening test for fall

43. cortical lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Aphasia - neglect - agnosia - acalculia etc
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

44. infections in GBS
EPV - campylobacter - HSV
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor
IVIG and plasmapheresis

45. lesion in dominant parietal lobe
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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;
Difficulty in writing - calculating - distinguishing left and write

46. impaired vibration and increased DTR
Gilberts disease
Vitamin B12 deficiency
Acetylecholinersterase inhibitors
Normal pressure hydrocephalus

47. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aspirin - control HTN and swallow eval before giving any oral meds
Clonidine will take care both high bp and withdrawal

48. 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;
Spastic paraparesis
Upright supine position
Femoral n lesion

49. excessive elevation of legs during walking (toe touch floor earlier than heels)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
It patient has electrolyte imbalance and hypothermia
Distal lower motor neuron disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

50. earliest sign of phenytoin toxicity
Cholinesterase inhibitor; and antiparkinsonism drugs
EPV - campylobacter - HSV
Reduced efficacy of OCP
Nystagmus on far lateral gaze