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

2. How to manage stroke patient came within 4 hours
Cerebellar 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
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;

3. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Nystagmus on far lateral gaze
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
High dose IV methyleprednisone;

4. best diagnosis for parkinsonim
Autospy gold standard
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS
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;

5. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spastic paraparesis
Aspirin - control HTN and swallow eval before giving any oral meds
Cholinesterase inhibitor; and antiparkinsonism drugs

6. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Get up from chair walk a short distance turn around and sit; screening test for fall
Spastic paraparesis
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
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

7. korsafoff psychosis
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

8. Tx of GBS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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.
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Entacapone - COMT inhibitor

9. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
RBC count >6000
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

10. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Nystagmus on far lateral gaze
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
High dose IV methyleprednisone;

11. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

12. differentiate picks and huntington
Vitamin B12 deficiency
Myasthenia; due to autoantibodies against acetylecholine receptor;
Lesion in nondominant temporal lobe
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

13. contraindication of sumatripta
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
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
Despite the term neuroma they arise from schwann cells - schwanoma
Coronary artery disease

14. How to prevent prevent frequency of MS exacerbation
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;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

15. dominant parietal lobe on the left side
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
90% of right handed and 60% of left handed persons; speech and language function
Upright supine position

16. lesion in dominant parietal lobe
Cerebral palsy; dx mri
Difficulty in writing - calculating - distinguishing left and write
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

17. at first tingling in toes and feet then weakness in extremities
Tunnel vision - diaphoresis - nausea - pallor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Not within 24 hours; give afte 24-48 hours if patient stable

18. phenytoin and OCP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Myasthenia; due to autoantibodies against acetylecholine receptor;
Reduced efficacy of OCP
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

19. What is can be used cluster headache prevention
Verapamil
Deficit in cranial nerve function
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)

20. 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
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
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;

21. get up and go test
Cerebellar lesion
Entacapone - COMT inhibitor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Get up from chair walk a short distance turn around and sit; screening test for fall

22. infections in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
EPV - campylobacter - HSV
Vitamin B12 deficiency
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

23. What percent of dementia is reversible
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
20%
IVIG and plasmapheresis

24. dementia plus urinary incontinence
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Normal pressure hydrocephalus

25. How to perform 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
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;
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
Cholinesterase inhibitor; and antiparkinsonism drugs

26. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Normal pressure hydrocephalus
Distal lower motor neuron disease

27. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Cerebral palsy; dx mri
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

28. medial thigh sensory loss and weakness in addcution
Aspirin - control HTN and swallow eval before giving any oral meds
RBC count >6000
Obturator n lesion
Autospy gold standard

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

30. How to differentiate parkinson and benign essential tremor
Obturator n lesion
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
82% specific for dementia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

31. How to confirm braindeath?
Autospy gold standard
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
MS

32. brain stem lesion
Spastic paraparesis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Deficit in cranial nerve function
RBC count >6000

33. How to tx acute exacerbation of MS
Deficit in cranial nerve function
High dose IV methyleprednisone;
Difficulty in writing - calculating - distinguishing left and write
Entacapone - COMT inhibitor

34. botulism
Lesion in nondominant temporal lobe
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
82% specific for dementia
Antitoxin

35. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Autospy gold standard
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

36. What is pronator drift
Cerebral palsy; dx mri
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
Distal lower motor neuron disease
Gilberts disease

37. What mmse score suggest dementia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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%
<20; if patient scores >25 benign forgetfulness

38. Patient with carbamazepine; What should be advice?
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

39. MMSE score of less than 24
Despite the term neuroma they arise from schwann cells - schwanoma
82% specific for dementia
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
Upright supine position

40. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position

41. earliest sign of phenytoin toxicity
Botulism has descending paralysis in contrast othere have ascending paralysis
Nystagmus on far lateral gaze
Lesion in nondominant temporal lobe
Entacapone - COMT inhibitor

42. double vision at the end of day and ptosis
RBC count >6000
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Cerebellar lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;

43. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Aspirin - control HTN and swallow eval before giving any oral meds
90% of right handed and 60% of left handed persons; speech and language function
Acetylecholinersterase inhibitors

44. prodrome of vasovagal syncope
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Antitoxin
Tunnel vision - diaphoresis - nausea - pallor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

45. cluster headache
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Not within 24 hours; give afte 24-48 hours if patient stable
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
Coronary artery disease

46. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Verapamil
Diabetes insipidus
Acetylecholinersterase inhibitors

47. impaired hepatic conjugation of billirubin
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.
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Gilberts disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

48. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
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.
RBC count >6000

49. stroke with lower facial palsy - pronator drift despite on aspirin
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

50. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Difficulty in writing - calculating - distinguishing left and write
Acetylecholinersterase inhibitors
Upright supine position