Test your basic knowledge |

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. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Distal lower motor neuron disease
Taper gradually to prevent seizure relapse
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

2. Unable to copy of matchstick - unable to dress up
<20; if patient scores >25 benign forgetfulness
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Construction apraxia; lesion in non dominant parietal lobe (right)

3. MG
Acetylecholinersterase inhibitors
Entacapone - COMT inhibitor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency

4. When to use brain spect scintigraphy to confirm brain death
MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
It patient has electrolyte imbalance and hypothermia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

5. lesion in dominant tempora lobe
82% specific for dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

6. double vision at the end of day and ptosis
EPV - campylobacter - HSV
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;

7. korsafoff psychosis
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
Botulism has descending paralysis in contrast othere have ascending paralysis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

8. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Aspirin - control HTN and swallow eval before giving any oral meds
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aphasia - neglect - agnosia - acalculia etc
Wernicke's encephalopathy; due to thiamine definition; medical emergency

9. What percent of dementia is reversible
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Distal lower motor neuron disease
20%

10. stroke with lower facial palsy - pronator drift despite on aspirin
Difficulty in writing - calculating - distinguishing left and write
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

11. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP
Diabetes insipidus
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

12. What is can be used cluster headache prevention
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

13. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Tunnel vision - diaphoresis - nausea - pallor
RBC count >6000
High dose IV methyleprednisone;

14. How to differentiate parkinson and benign essential tremor
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Aphasia - neglect - agnosia - acalculia etc
Nystagmus on far lateral gaze

15. When to start fibrinolytic therapy in stroke patient?
Gilberts disease
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
Aspirin - control HTN and swallow eval before giving any oral meds

16. craniopharyngioma
Lesion in nondominant temporal lobe
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
Diabetes insipidus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

17. How to differentiate medial and lateral medullary syndrome
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;
Wernicke's encephalopathy; due to thiamine definition; medical emergency

18. excessive elevation of legs during walking (toe touch floor earlier than heels)
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

19. benign essential tremor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Propranolol or primidone
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Autospy gold standard

20. impaired perception of complex sounds
Normal pressure hydrocephalus
Lesion in nondominant temporal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Aphasia - neglect - agnosia - acalculia etc

21. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Distal lower motor neuron disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

22. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Aspirin - control HTN and swallow eval before giving any oral meds
Autospy gold standard
Despite the term neuroma they arise from schwann cells - schwanoma

23. GBS
IVIG and plasmapheresis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Propranolol or primidone

24. Should we tx htn in acute ischemic stroke

25. How to tx lewy body dementia
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors

26. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
EPV - campylobacter - HSV
Distal lower motor neuron disease
Lesion in nondominant temporal lobe

27. How to differentiate medial and lateral pontine syndrome
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

28. differentiate lewy body dementia and vascular dementia
Reduced efficacy of OCP
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
82% specific for dementia
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

29. How to confirm braindeath?
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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.
<20; if patient scores >25 benign forgetfulness
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

30. How to stop antiepileptic drugs
Acetylecholinersterase inhibitors
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Taper gradually to prevent seizure relapse
IVIG and plasmapheresis

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

32. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebral palsy; dx mri
RBC count >6000
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

33. How to tx stroke patient came after 6h
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tunnel vision - diaphoresis - nausea - pallor
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds

34. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Clonidine will take care both high bp and withdrawal
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

35. How to prevent prevent frequency of MS exacerbation
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

36. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Clonidine will take care both high bp and withdrawal
Cholinesterase inhibitor; and antiparkinsonism drugs

37. impaired vibration and increased DTR
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
Vitamin B12 deficiency
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;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

38. differentiate picks and huntington
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Taper gradually to prevent seizure relapse
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

39. cluster headache
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
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

40. Patient with carbamazepine; What should be advice?
<20; if patient scores >25 benign forgetfulness
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
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
Femoral n lesion

41. How to differentiate dementias
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
Corticosteroid and acyclovir
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

42. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Verapamil
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

43. What is pronator drift
Cholinesterase inhibitor; and antiparkinsonism drugs
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
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

44. medial thigh sensory loss and weakness in addcution
Antitoxin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Obturator n lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

45. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Get up from chair walk a short distance turn around and sit; screening test for fall
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

46. When headache is presenting complaint of brain tumor
Gilberts disease
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
High dose IV methyleprednisone;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

47. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Entacapone - COMT inhibitor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Gilberts disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

48. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
EPV - campylobacter - HSV
Cerebellar lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

49. 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
Antitoxin
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
Acetylecholinersterase inhibitors

50. impaired hepatic conjugation of billirubin
Entacapone - COMT inhibitor
Construction apraxia; lesion in non dominant parietal lobe (right)
Gilberts disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA