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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. Tx of GBS
Construction apraxia; lesion in non dominant parietal lobe (right)
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aspirin - control HTN and swallow eval before giving any oral meds

2. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Autospy gold standard
Femoral n lesion
Taper gradually to prevent seizure relapse

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

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4. acoustic neuroma
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable
It patient has electrolyte imbalance and hypothermia
Despite the term neuroma they arise from schwann cells - schwanoma

5. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Corticosteroid and acyclovir
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Deficit in cranial nerve function
Not within 24 hours; give afte 24-48 hours if patient stable

6. What is pronator drift
Diabetes insipidus
Gilberts disease
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
Cholinesterase inhibitor; and antiparkinsonism drugs

7. excessive elevation of legs during walking (toe touch floor earlier than heels)
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Diabetes insipidus
Distal lower motor neuron disease
<20; if patient scores >25 benign forgetfulness

8. How to differentiate dementias
RBC count >6000
Taper gradually to prevent seizure relapse
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

9. infections in GBS
Coronary artery disease
EPV - campylobacter - HSV
Antitoxin
20%

10. How to confirm braindeath?
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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.
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
82% specific for dementia

11. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Autospy gold standard
Deficit in cranial nerve function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

12. How to perform apnea test
EPV - campylobacter - HSV
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

13. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Femoral n lesion
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.
Cerebellar lesion
Coronary artery disease

14. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Deficit in cranial nerve function
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
Lesion in nondominant temporal lobe

15. craniopharyngioma
Obturator n lesion
Diabetes insipidus
Deficit in cranial nerve function
Verapamil

16. phenytoin and OCP
Cerebellar lesion
Reduced efficacy of OCP
Despite the term neuroma they arise from schwann cells - schwanoma
Cholinesterase inhibitor; and antiparkinsonism drugs

17. How to prevent prevent frequency of MS exacerbation
Construction apraxia; lesion in non dominant parietal lobe (right)
Diabetes insipidus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
20%

18. What percent of dementia is reversible
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%
Get up from chair walk a short distance turn around and sit; screening test for fall
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

19. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Get up from chair walk a short distance turn around and sit; screening test for fall
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

20. prodrome of vasovagal syncope
Get up from chair walk a short distance turn around and sit; screening test for fall
Lesion in nondominant temporal lobe
Tunnel vision - diaphoresis - nausea - pallor
Deficit in cranial nerve function

21. How to differentiate parkinson and benign essential tremor
It patient has electrolyte imbalance and hypothermia
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
Upright supine position

22. dominant parietal lobe on the left side
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
Spastic paraparesis
It patient has electrolyte imbalance and hypothermia

23. botulism
Cholinesterase inhibitor; and antiparkinsonism drugs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Botulism has descending paralysis in contrast othere have ascending paralysis
Antitoxin

24. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Deficit in cranial nerve function
Upright supine position
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

25. How to manage stroke patient came within 4 hours
Construction apraxia; lesion in non dominant parietal lobe (right)
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Taper gradually to prevent seizure relapse

26. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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.

27. How to stop antiepileptic drugs
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Taper gradually to prevent seizure relapse
Entacapone - COMT inhibitor

28. Why V12 deficient develop hypokalemia after tx with b12
Botulism has descending paralysis in contrast othere have ascending paralysis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

29. differentiate picks and huntington
Not within 24 hours; give afte 24-48 hours if patient stable
Myasthenia; due to autoantibodies against acetylecholine receptor;
MS
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

30. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Antitoxin
Wernicke's encephalopathy; due to thiamine definition; medical emergency

31. Tx of bells palsy
Corticosteroid and acyclovir
Propranolol or primidone
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

32. women with unilateral eye pain; neurlogic symptoms here there at different times
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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

33. When to suspect traumatic LP
RBC count >6000
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

34. What mmse score suggest dementia
82% specific for dementia
<20; if patient scores >25 benign forgetfulness
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Despite the term neuroma they arise from schwann cells - schwanoma

35. best diagnosis for parkinsonim
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Botulism has descending paralysis in contrast othere have ascending paralysis
Autospy gold standard
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

36. How to differentiate medial and lateral medullary syndrome
IVIG and plasmapheresis
Propranolol or primidone
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;
Upright supine position

37. medial thigh sensory loss and weakness in addcution
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Obturator n lesion

38. How to differentiate traumatic LP and SAH
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
90% of right handed and 60% of left handed persons; speech and language function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

39. earliest sign of phenytoin toxicity
Get up from chair walk a short distance turn around and sit; screening test for fall
Corticosteroid and acyclovir
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Nystagmus on far lateral gaze

40. labyrinthitis
Vitamin B12 deficiency
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

41. differentiate lewy body dementia and vascular dementia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Reduced efficacy of OCP
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

42. Should we tx htn in acute ischemic stroke

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43. How to tx acute exacerbation of MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
High dose IV methyleprednisone;
Autospy gold standard

44. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Entacapone - COMT inhibitor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

45. at first tingling in toes and feet then weakness in extremities
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Gilberts disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse

46. When to use brain spect scintigraphy to confirm brain death
Lesion in nondominant temporal lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
It patient has electrolyte imbalance and hypothermia
Get up from chair walk a short distance turn around and sit; screening test for fall

47. How to differentiate medial and lateral pontine syndrome
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Obturator n lesion
Antitoxin

48. differentiate wenicke and korsakoff
Taper gradually to prevent seizure relapse
High dose IV methyleprednisone;
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

49. Patient with carbamazepine; What should be advice?
Distal lower motor neuron disease
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
Vitamin B12 deficiency
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

50. double vision at the end of day and ptosis
Diabetes insipidus
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Femoral n lesion