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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 stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Distal lower motor neuron disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

2. cluster headache
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in writing - calculating - distinguishing left and write
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
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

3. acoustic neuroma
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Despite the term neuroma they arise from schwann cells - schwanoma
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

4. What percent of dementia is reversible
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
20%
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

5. indication of plasmapheresis in GBS
Botulism has descending paralysis in contrast othere have ascending paralysis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spastic paraparesis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

6. impaired vibration and increased DTR
Acetylecholinersterase inhibitors
Vitamin B12 deficiency
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Aspirin - control HTN and swallow eval before giving any oral meds

7. MG
Acetylecholinersterase inhibitors
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

8. stroke with lower facial palsy - pronator drift despite on aspirin
Normal pressure hydrocephalus
Vitamin B12 deficiency
MS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

9. 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
<20; if patient scores >25 benign forgetfulness
90% of right handed and 60% of left handed persons; speech and language function

10. anerior and anteriomedial thigh paresthesia - decreased DTR
Corticosteroid and acyclovir
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Femoral n lesion
82% specific for dementia

11. How to differentiate medial and lateral pontine syndrome
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; 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
Diabetes insipidus
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

12. How to differentiate dementias
Botulism has descending paralysis in contrast othere have ascending paralysis
Normal pressure hydrocephalus
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

13. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Diabetes insipidus
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

14. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Clonidine will take care both high bp and withdrawal
Antitoxin
Construction apraxia; lesion in non dominant parietal lobe (right)

15. lesion in dominant tempora 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis
Autospy gold standard

16. medial thigh sensory loss and weakness in addcution
Obturator n lesion
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aphasia - neglect - agnosia - acalculia etc

17. What is can be used cluster headache prevention
Verapamil
Gilberts disease
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

18. Tx of bells palsy
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Corticosteroid and acyclovir

19. GBS
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

20. How to differentiate botulism from tick born paralysis - GBS and MG
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Vitamin B12 deficiency
Botulism has descending paralysis in contrast othere have ascending paralysis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

21. benign essential tremor
90% of right handed and 60% of left handed persons; speech and language function
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

22. 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
MS
82% specific for dementia
Deficit in cranial nerve function

23. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Myasthenia; due to autoantibodies against acetylecholine receptor;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

24. How to differentiate traumatic LP and SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Vitamin B12 deficiency

25. excessive elevation of legs during walking (toe touch floor earlier than heels)
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Distal lower motor neuron 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
EPV - campylobacter - HSV

26. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
EPV - campylobacter - HSV
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebral palsy; dx mri

27. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Propranolol or primidone
High dose IV methyleprednisone;
Femoral n lesion

28. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Entacapone - COMT inhibitor
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
Coronary artery disease

29. korsafoff psychosis
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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 glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

30. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Nystagmus on far lateral gaze
Clonidine will take care both high bp and withdrawal

31. When to suspect traumatic LP
High dose IV methyleprednisone;
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.
RBC count >6000

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

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33. What mmse score suggest dementia
20%
<20; if patient scores >25 benign forgetfulness
RBC count >6000
Botulism has descending paralysis in contrast othere have ascending paralysis

34. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Clonidine will take care both high bp and withdrawal

35. dementia plus urinary incontinence
Get up from chair walk a short distance turn around and sit; screening test for fall
Normal pressure hydrocephalus
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Corticosteroid and acyclovir

36. How to perform apnea test
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Nystagmus on far lateral gaze

37. When to use brain spect scintigraphy to confirm brain death
EPV - campylobacter - HSV
It patient has electrolyte imbalance and hypothermia
Not within 24 hours; give afte 24-48 hours if patient stable
Autospy gold standard

38. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Construction apraxia; lesion in non dominant parietal lobe (right)
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Distal lower motor neuron disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

39. How to tx stroke patient came after 6h
<20; if patient scores >25 benign forgetfulness
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone

40. phenytoin and OCP
Reduced efficacy of OCP
Obturator n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

41. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Gilberts disease
<20; if patient scores >25 benign forgetfulness

42. differentiate wenicke and korsakoff
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
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
Reduced efficacy of OCP

43. How to prevent prevent frequency of MS exacerbation
High dose IV methyleprednisone;
Upright supine position
MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

44. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Clonidine will take care both high bp and withdrawal
Propranolol or primidone
Myasthenia; due to autoantibodies against acetylecholine receptor;

45. Acute onset of left arm weakness
Taper gradually to prevent seizure relapse
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Diabetes insipidus
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

46. craniopharyngioma
Autospy gold standard
Not within 24 hours; give afte 24-48 hours if patient stable
Difficulty in writing - calculating - distinguishing left and write
Diabetes insipidus

47. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Not within 24 hours; give afte 24-48 hours if patient stable
Coronary artery disease
Upright supine position
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

48. prodrome of vasovagal syncope
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;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Verapamil
Tunnel vision - diaphoresis - nausea - pallor

49. oligoclonal band in CSF
Obturator n lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MS
Get up from chair walk a short distance turn around and sit; screening test for fall

50. 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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin