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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 prevent prevent frequency of MS exacerbation
Deficit in cranial nerve function
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Propranolol or primidone
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

2. indication of plasmapheresis in GBS
Myasthenia; due to autoantibodies against acetylecholine receptor;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Lesion in nondominant temporal lobe

3. What is can be used cluster headache prevention
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
<20; if patient scores >25 benign forgetfulness
Myasthenia; due to autoantibodies against acetylecholine receptor;

4. MG
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Antitoxin
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acetylecholinersterase inhibitors

5. Why V12 deficient develop hypokalemia after tx with b12
Diabetes insipidus
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

6. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Get up from chair walk a short distance turn around and sit; screening test for fall
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

7. Acute onset of left arm weakness
Tunnel vision - diaphoresis - nausea - pallor
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Autospy gold standard
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

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

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9. botulism
Obturator n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Antitoxin
Aspirin - control HTN and swallow eval before giving any oral meds

10. 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
Aphasia - neglect - agnosia - acalculia etc
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Vitamin B12 deficiency

11. what drug is used to extend effects of levodopa
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Entacapone - COMT inhibitor
MS
Difficulty in writing - calculating - distinguishing left and write

12. What mmse score suggest dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
<20; if patient scores >25 benign forgetfulness
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Obturator n lesion

13. differentiate lewy body dementia and vascular dementia
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.
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

14. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Lesion in nondominant temporal lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

15. contraindication of sumatripta
Coronary artery disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Vitamin B12 deficiency
Upright supine position

16. best diagnosis for parkinsonim
Autospy gold standard
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

17. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
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.
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;
Reduced efficacy of OCP

18. When to use brain spect scintigraphy to confirm brain death
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
It patient has electrolyte imbalance and hypothermia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

19. at first tingling in toes and feet then weakness in extremities
Clonidine will take care both high bp and withdrawal
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

20. excessive elevation of legs during walking (toe touch floor earlier than heels)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Distal lower motor neuron disease
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
Difficulty in writing - calculating - distinguishing left and write

21. Blood transfusion in hypothermia
Vitamin B12 deficiency
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

22. When to suspect traumatic LP
Get up from chair walk a short distance turn around and sit; screening test for fall
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
RBC count >6000
Lesion in nondominant temporal lobe

23. dementia plus urinary incontinence
Normal pressure hydrocephalus
Verapamil
Spastic paraparesis
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

24. cluster headache
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Nystagmus on far lateral gaze

25. When to use dopamine agonist pramipexol in parkinson
82% specific for dementia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Entacapone - COMT inhibitor

26. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
High dose IV methyleprednisone;

27. How to differentiate parkinson and benign essential tremor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Aspirin - control HTN and swallow eval before giving any oral meds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

28. How to stop antiepileptic drugs
Upright supine position
RBC count >6000
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
Taper gradually to prevent seizure relapse

29. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

30. cortical lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tunnel vision - diaphoresis - nausea - pallor
Aphasia - neglect - agnosia - acalculia etc
Upright supine position

31. medial thigh sensory loss and weakness in addcution
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
IVIG and plasmapheresis
Obturator n lesion

32. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Cerebellar lesion
Upright supine position
Taper gradually to prevent seizure relapse

33. acoustic neuroma
Vitamin B12 deficiency
Despite the term neuroma they arise from schwann cells - schwanoma
Verapamil
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

34. differentiate wenicke and korsakoff
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

35. Patient with carbamazepine; What should be advice?
Not within 24 hours; give afte 24-48 hours if patient stable
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
Difficulty in writing - calculating - distinguishing left and write

36. lesion in dominant parietal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write
Aspirin - control HTN and swallow eval before giving any oral meds

37. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
IVIG and plasmapheresis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Vitamin B12 deficiency

38. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

39. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
82% specific for dementia
Cholinesterase inhibitor; and antiparkinsonism drugs

40. Should we tx htn in acute ischemic stroke

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41. impaired vibration and increased DTR
82% specific for dementia
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
Normal pressure hydrocephalus
Vitamin B12 deficiency

42. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Deficit in cranial nerve function

43. How to perform 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
Cerebral palsy; dx mri
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Distal lower motor neuron disease

44. Tx of bells palsy
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
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

45. 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
High dose IV methyleprednisone;
Not within 24 hours; give afte 24-48 hours if patient stable

46. oligoclonal band in CSF
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS
Difficulty in writing - calculating - distinguishing left and write
Myasthenia; due to autoantibodies against acetylecholine receptor;

47. phenytoin and OCP
Reduced efficacy of OCP
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
Propranolol or primidone
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

48. 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
Acetylecholinersterase inhibitors
Obturator n lesion
Antitoxin

49. brain stem lesion
Deficit in cranial nerve function
Lesion in nondominant temporal lobe
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spastic paraparesis

50. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Not within 24 hours; give afte 24-48 hours if patient stable
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal