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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. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Get up from chair walk a short distance turn around and sit; screening test for fall
Not within 24 hours; give afte 24-48 hours if patient stable

2. at first tingling in toes and feet then weakness in extremities
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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

3. Blood transfusion in hypothermia
Femoral n lesion
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

4. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Corticosteroid and acyclovir
Diabetes insipidus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

5. 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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebral palsy; dx mri

6. acoustic neuroma
RBC count >6000
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Despite the term neuroma they arise from schwann cells - schwanoma
Get up from chair walk a short distance turn around and sit; screening test for fall

7. How to differentiate traumatic LP and SAH
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

8. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Aphasia - neglect - agnosia - acalculia etc
Distal lower motor neuron disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

9. When to give aspirin when patient on tPA after stroke
Antitoxin
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
Not within 24 hours; give afte 24-48 hours if patient stable
Clonidine will take care both high bp and withdrawal

10. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Despite the term neuroma they arise from schwann cells - schwanoma
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

11. excessive elevation of legs during walking (toe touch floor earlier than heels)
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Upright supine position

12. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebral palsy; dx mri
Vitamin B12 deficiency
Verapamil

13. labyrinthitis
Tunnel vision - diaphoresis - nausea - pallor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Follows viral illness; vertigo - tinnitus - nausea. self limiting
It patient has electrolyte imbalance and hypothermia

14. impaired hepatic conjugation of billirubin
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
Taper gradually to prevent seizure relapse
Gilberts disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

15. best diagnosis for parkinsonim
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Autospy gold standard
Distal lower motor neuron disease

16. earliest sign of phenytoin toxicity
Difficulty in writing - calculating - distinguishing left and write
Propranolol or primidone
Cerebellar lesion
Nystagmus on far lateral gaze

17. differentiate picks and huntington
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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

18. cortical lesion
Vitamin B12 deficiency
Aphasia - neglect - agnosia - acalculia etc
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Despite the term neuroma they arise from schwann cells - schwanoma

19. botulism
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;
Not within 24 hours; give afte 24-48 hours if patient stable
Antitoxin
20%

20. korsafoff psychosis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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

21. medial thigh sensory loss and weakness in addcution
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Obturator n lesion
Coronary artery disease

22. Why V12 deficient develop hypokalemia after tx with b12
Cerebral palsy; dx mri
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;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
High dose IV methyleprednisone;

23. benign essential tremor
Clonidine will take care both high bp and withdrawal
Deficit in cranial nerve function
Propranolol or primidone
Autospy gold standard

24. Acute onset of left arm weakness
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

25. Tx of GBS
Reduced efficacy of OCP
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Acetylecholinersterase inhibitors
Myasthenia; due to autoantibodies against acetylecholine receptor;

26. differentiate wenicke and korsakoff
Difficulty in writing - calculating - distinguishing left and write
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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

27. When to suspect traumatic LP
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Nystagmus on far lateral gaze
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
RBC count >6000

28. Patient with carbamazepine; What should be advice?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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

29. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
82% specific for dementia
It patient has electrolyte imbalance and hypothermia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

30. When to start fibrinolytic therapy in stroke patient?
Construction apraxia; lesion in non dominant parietal lobe (right)
Corticosteroid and acyclovir
Obturator n lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

31. oligoclonal band in CSF
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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. 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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebellar lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

33. prodrome of vasovagal syncope
Verapamil
20%
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Tunnel vision - diaphoresis - nausea - pallor

34. Tx of bells palsy
Corticosteroid and acyclovir
Lesion in nondominant temporal lobe
Normal pressure hydrocephalus
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

35. When to use brain spect scintigraphy to confirm brain death
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
It patient has electrolyte imbalance and hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

36. craniopharyngioma
RBC count >6000
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Diabetes insipidus

37. Unable to copy of matchstick - unable to dress up
Not within 24 hours; give afte 24-48 hours if patient stable
Construction apraxia; lesion in non dominant parietal lobe (right)
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Follows viral illness; vertigo - tinnitus - nausea. self limiting

38. How to stop antiepileptic drugs
Aphasia - neglect - agnosia - acalculia etc
Taper gradually to prevent seizure relapse
Tunnel vision - diaphoresis - nausea - pallor
Propranolol or primidone

39. How to prevent prevent frequency of MS exacerbation
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Acetylecholinersterase inhibitors
Coronary artery disease

40. double vision at the end of day and ptosis
Get up from chair walk a short distance turn around and sit; screening test for fall
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cholinesterase inhibitor; and antiparkinsonism drugs

41. How to differentiate medial and lateral medullary syndrome
Cholinesterase inhibitor; and antiparkinsonism drugs
Myasthenia; due to autoantibodies against acetylecholine receptor;
Lesion in nondominant temporal lobe
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;

42. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Clonidine will take care both high bp and withdrawal
82% specific for dementia

43. How to differentiate botulism from tick born paralysis - GBS and MG
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV

44. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Construction apraxia; lesion in non dominant parietal lobe (right)
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
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. impaired vibration and increased DTR
Autospy gold standard
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Vitamin B12 deficiency

46. what drug is used to extend effects of levodopa
MS
Construction apraxia; lesion in non dominant parietal lobe (right)
82% specific for dementia
Entacapone - COMT inhibitor

47. dementia plus urinary incontinence
Normal pressure hydrocephalus
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spastic paraparesis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

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

49. infections in GBS
Coronary artery disease
Cholinesterase inhibitor; and antiparkinsonism drugs
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
EPV - campylobacter - HSV

50. MG
EPV - campylobacter - HSV
Obturator n lesion
Acetylecholinersterase inhibitors
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;