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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. When to suspect traumatic LP
RBC count >6000
Botulism has descending paralysis in contrast othere have ascending paralysis
82% specific for dementia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

2. Tx of GBS
IVIG and plasmapheresis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
<20; if patient scores >25 benign forgetfulness

3. When to start fibrinolytic therapy in stroke patient?
Cerebral palsy; dx mri
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse

4. botulism
Nystagmus on far lateral gaze
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
Antitoxin
Botulism has descending paralysis in contrast othere have ascending paralysis

5. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Corticosteroid and acyclovir
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Aspirin - control HTN and swallow eval before giving any oral meds

6. Unable to copy of matchstick - unable to dress up
82% specific for dementia
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
Femoral n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)

7. 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
Clonidine will take care both high bp and withdrawal
Corticosteroid and acyclovir
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

8. get up and go test
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
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

9. How to tx acute exacerbation of MS
RBC count >6000
Lesion in nondominant temporal lobe
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
High dose IV methyleprednisone;

10. When headache is presenting complaint of brain tumor
Aspirin - control HTN and swallow eval before giving any oral meds
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

11. 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
IVIG and plasmapheresis
Gilberts disease
Construction apraxia; lesion in non dominant parietal lobe (right)

12. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Despite the term neuroma they arise from schwann cells - schwanoma
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Spastic paraparesis

13. How to stop antiepileptic drugs
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Difficulty in writing - calculating - distinguishing left and write
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

14. What is pronator drift
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
<20; if patient scores >25 benign forgetfulness
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

15. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

16. How to differentiate parkinson and benign essential tremor
Acetylecholinersterase inhibitors
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Clonidine will take care both high bp and withdrawal

17. What percent of dementia is reversible
Distal lower motor neuron disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
20%
Autospy gold standard

18. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Cerebral palsy; dx mri
Verapamil
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

19. How to manage stroke patient came within 4 hours
Lesion in nondominant temporal lobe
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Nystagmus on far lateral gaze
Obturator n lesion

20. How to prevent prevent frequency of MS exacerbation
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Clonidine will take care both high bp and withdrawal

21. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

22. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
High dose IV methyleprednisone;
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

23. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Taper gradually to prevent seizure relapse
Tunnel vision - diaphoresis - nausea - pallor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

24. dementia plus urinary incontinence
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
IVIG and plasmapheresis
Gilberts disease
Normal pressure hydrocephalus

25. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Vitamin B12 deficiency
Propranolol or primidone
Distal lower motor neuron disease

26. 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
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;
20%

27. GBS
Diabetes insipidus
IVIG and plasmapheresis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

28. impaired vibration and increased DTR
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency

29. indication of plasmapheresis in GBS
Construction apraxia; lesion in non dominant parietal lobe (right)
Deficit in cranial nerve function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Taper gradually to prevent seizure relapse

30. MMSE score of less than 24
Difficulty in writing - calculating - distinguishing left and write
82% specific for dementia
EPV - campylobacter - HSV
Construction apraxia; lesion in non dominant parietal lobe (right)

31. women with unilateral eye pain; neurlogic symptoms here there at different times
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: CSF increased IgG -IgM and IgA also increased. not specific to MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Propranolol or primidone

32. differentiate lewy body dementia and vascular dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Propranolol or primidone
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
Normal pressure hydrocephalus

33. What is can be used cluster headache prevention
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
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
Verapamil

34. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Vitamin B12 deficiency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebral palsy; dx mri

35. Tx of bells palsy
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Corticosteroid and acyclovir

36. 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.
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Propranolol or primidone

37. lesion in dominant tempora lobe
Diabetes insipidus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Acetylecholinersterase inhibitors

38. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
90% of right handed and 60% of left handed persons; speech and language function
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebellar lesion

39. Patient with carbamazepine; What should be advice?
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

40. Should we tx htn in acute ischemic stroke

41. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Aspirin - control HTN and swallow eval before giving any oral meds
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Femoral n lesion

42. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Nystagmus on far lateral gaze
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

43. contraindication of sumatripta
Coronary artery disease
20%
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Not within 24 hours; give afte 24-48 hours if patient stable

44. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Entacapone - COMT inhibitor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
RBC count >6000

45. at first tingling in toes and feet then weakness in extremities
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

46. impaired hepatic conjugation of billirubin
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Despite the term neuroma they arise from schwann cells - schwanoma
Gilberts disease

47. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in writing - calculating - distinguishing left and write
<20; if patient scores >25 benign forgetfulness
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

48. differentiate wenicke and korsakoff
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Not within 24 hours; give afte 24-48 hours if patient stable
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

49. What mmse score suggest dementia
20%
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
<20; if patient scores >25 benign forgetfulness

50. brain stem lesion
Obturator n lesion
Deficit in cranial nerve function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Vitamin B12 deficiency