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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. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Gilberts disease
Spastic paraparesis
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)

2. cortical lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aphasia - neglect - agnosia - acalculia etc
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

3. differentiate picks and huntington
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

4. Should we tx htn in acute ischemic stroke

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5. Tx of bells palsy
Corticosteroid and acyclovir
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

6. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
20%
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in writing - calculating - distinguishing left and write

7. How to differentiate dementias
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
High dose IV methyleprednisone;

8. differentiate lewy body dementia and vascular dementia
Coronary artery disease
90% of right handed and 60% of left handed persons; speech and language function
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
Spastic paraparesis

9. How to tx acute exacerbation of MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
High dose IV methyleprednisone;
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

10. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Deficit in cranial nerve function
Antitoxin

11. dominant parietal lobe on the left side
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;
EPV - campylobacter - HSV
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
90% of right handed and 60% of left handed persons; speech and language function

12. When to use brain spect scintigraphy to confirm brain death
RBC count >6000
Antitoxin
It patient has electrolyte imbalance and hypothermia
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

13. How to differentiate medial and lateral medullary syndrome
Verapamil
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
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;
MS

14. Unable to copy of matchstick - unable to dress up
20%
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Acetylecholinersterase inhibitors

15. How to manage stroke patient came within 4 hours
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Aspirin - control HTN and swallow eval before giving any oral meds
Despite the term neuroma they arise from schwann cells - schwanoma

16. How to stop antiepileptic drugs
Tunnel vision - diaphoresis - nausea - pallor
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Taper gradually to prevent seizure relapse

17. stroke with lower facial palsy - pronator drift despite on aspirin
Cholinesterase inhibitor; and antiparkinsonism drugs
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

18. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Femoral n lesion
Gilberts disease

19. 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
Propranolol or primidone
Aphasia - neglect - agnosia - acalculia etc
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

20. When to give aspirin when patient on tPA after stroke
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Not within 24 hours; give afte 24-48 hours if patient stable
Verapamil
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

21. lesion in dominant tempora lobe
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Verapamil
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

22. medial thigh sensory loss and weakness in addcution
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Clonidine will take care both high bp and withdrawal

23. What is can be used cluster headache prevention
Verapamil
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Clonidine will take care both high bp and withdrawal

24. 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.
Not within 24 hours; give afte 24-48 hours if patient stable
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Construction apraxia; lesion in non dominant parietal lobe (right)

25. craniopharyngioma
Tunnel vision - diaphoresis - nausea - pallor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Diabetes insipidus
Entacapone - COMT inhibitor

26. What is pronator drift
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.
Clonidine will take care both high bp and withdrawal
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
Femoral n lesion

27. labyrinthitis
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

28. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Antitoxin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

29. How to differentiate parkinson and benign essential tremor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Propranolol or primidone

30. 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
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
Entacapone - COMT inhibitor

31. When headache is presenting complaint of brain tumor
Autospy gold standard
Entacapone - COMT inhibitor
Nystagmus on far lateral gaze
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

32. anerior and anteriomedial thigh paresthesia - decreased DTR
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency
Femoral n lesion

33. MMSE score of less than 24
<20; if patient scores >25 benign forgetfulness
Get up from chair walk a short distance turn around and sit; screening test for fall
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.
82% specific for dementia

34. lesion in dominant parietal lobe
Normal pressure hydrocephalus
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
Difficulty in writing - calculating - distinguishing left and write

35. How to tx stroke patient came after 6h
Nystagmus on far lateral gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds
Diabetes insipidus

36. 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
Propranolol or primidone
Distal lower motor neuron disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

37. prodrome of vasovagal syncope
82% specific for dementia
Corticosteroid and acyclovir
Tunnel vision - diaphoresis - nausea - pallor
90% of right handed and 60% of left handed persons; speech and language function

38. Why V12 deficient develop hypokalemia after tx with b12
Upright supine position
Acetylecholinersterase inhibitors
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
90% of right handed and 60% of left handed persons; speech and language function

39. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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.
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

40. oligoclonal band in CSF
MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
20%
Corticosteroid and acyclovir

41. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Antitoxin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Deficit in cranial nerve function

42. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position
Autospy gold standard
Follows viral illness; vertigo - tinnitus - nausea. self limiting

43. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

44. cluster headache
Acetylecholinersterase inhibitors
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

45. How to differentiate medial and lateral pontine syndrome
Corticosteroid and acyclovir
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
Nystagmus on far lateral gaze
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

46. What mmse score suggest dementia
Aphasia - neglect - agnosia - acalculia etc
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
<20; if patient scores >25 benign forgetfulness

47. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Entacapone - COMT inhibitor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
It patient has electrolyte imbalance and hypothermia

48. benign essential tremor
Difficulty in writing - calculating - distinguishing left and write
Botulism has descending paralysis in contrast othere have ascending paralysis
Deficit in cranial nerve function
Propranolol or primidone

49. When to start fibrinolytic therapy in stroke patient?
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Deficit in cranial nerve function
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

50. dementia plus urinary incontinence
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
Normal pressure hydrocephalus
IVIG and plasmapheresis
Spastic paraparesis