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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. korsafoff psychosis
Propranolol or primidone
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%

2. Why V12 deficient develop hypokalemia after tx with b12
Aphasia - neglect - agnosia - acalculia etc
20%
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
<20; if patient scores >25 benign forgetfulness

3. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Nystagmus on far lateral gaze
Upright supine position

4. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Obturator n lesion
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

5. How to differentiate medial and lateral medullary syndrome
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;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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

6. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Aspirin - control HTN and swallow eval before giving any oral meds
Clonidine will take care both high bp and withdrawal

7. When to suspect traumatic LP
Obturator n lesion
RBC count >6000
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

8. best diagnosis for parkinsonim
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Autospy gold standard
Corticosteroid and acyclovir

9. infections in GBS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
EPV - campylobacter - HSV
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

10. What is can be used cluster headache prevention
Verapamil
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Cholinesterase inhibitor; and antiparkinsonism drugs

11. When headache is presenting complaint of brain tumor
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;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

12. Patient with carbamazepine; What should be advice?
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
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

13. benign essential tremor
Diabetes insipidus
Myasthenia; due to autoantibodies against acetylecholine receptor;
Propranolol or primidone
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

14. lesion in dominant parietal lobe
Vitamin B12 deficiency
Difficulty in writing - calculating - distinguishing left and write
Cerebellar lesion
Aphasia - neglect - agnosia - acalculia etc

15. How to prevent prevent frequency of MS exacerbation
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

16. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in writing - calculating - distinguishing left and write
Gilberts disease
It patient has electrolyte imbalance and hypothermia

17. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

18. MMSE score of less than 24
Aphasia - neglect - agnosia - acalculia etc
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

19. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Diabetes insipidus
High dose IV methyleprednisone;

20. differentiate wenicke and korsakoff
IVIG and plasmapheresis
Spastic paraparesis
Nystagmus on far lateral gaze
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

21. botulism
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
Cholinesterase inhibitor; and antiparkinsonism drugs
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

22. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Clonidine will take care both high bp and withdrawal
Autospy gold standard
Diabetes insipidus

23. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
Cholinesterase inhibitor; and antiparkinsonism drugs
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

24. cluster headache
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

25. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Lesion in nondominant temporal 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
Cholinesterase inhibitor; and antiparkinsonism drugs

26. When to use brain spect scintigraphy to confirm brain death
High dose IV methyleprednisone;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
It patient has electrolyte imbalance and hypothermia
RBC count >6000

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

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28. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in writing - calculating - distinguishing left and write

29. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Not within 24 hours; give afte 24-48 hours if patient stable
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

30. MG
Get up from chair walk a short distance turn around and sit; screening test for fall
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)
Acetylecholinersterase inhibitors

31. brain stem lesion
Cerebral palsy; dx mri
Deficit in cranial nerve function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Lesion in nondominant temporal lobe

32. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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 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
Cerebellar lesion

33. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors
Aphasia - neglect - agnosia - acalculia etc
20%

34. impaired vibration and increased DTR
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Vitamin B12 deficiency
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.

35. contraindication of sumatripta
IVIG and plasmapheresis
Cerebellar lesion
Coronary artery disease
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

36. How to differentiate traumatic LP and SAH
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

37. differentiate lewy body dementia and vascular dementia
Cerebellar lesion
Acetylecholinersterase inhibitors
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
Tunnel vision - diaphoresis - nausea - pallor

38. How to perform apnea test
Get up from chair walk a short distance turn around and sit; screening test for fall
High dose IV methyleprednisone;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Obturator n lesion

39. When to start fibrinolytic therapy in stroke patient?
Normal pressure hydrocephalus
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
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.

40. How to stop antiepileptic drugs
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
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable

41. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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;
Aspirin - control HTN and swallow eval before giving any oral meds
Cerebral palsy; dx mri
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

42. impaired hepatic conjugation of billirubin
Gilberts disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Get up from chair walk a short distance turn around and sit; screening test for fall
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

43. How to tx lewy body dementia
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
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Cholinesterase inhibitor; and antiparkinsonism drugs

44. oligoclonal band in CSF
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MS
Upright supine position
Spastic paraparesis

45. Should we tx htn in acute ischemic stroke

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46. women with unilateral eye pain; neurlogic symptoms here there at different times
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
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
Corticosteroid and acyclovir

47. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency
Lesion in nondominant temporal lobe
Distal lower motor neuron disease

48. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Normal pressure hydrocephalus

49. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Distal lower motor neuron disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Autospy gold standard

50. phenytoin and OCP
Reduced efficacy of OCP
Corticosteroid and acyclovir
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal