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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. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Obturator n lesion
Reduced efficacy of OCP
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

2. MG
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Acetylecholinersterase inhibitors

3. at first tingling in toes and feet then weakness in extremities
Gilberts disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

4. botulism
Antitoxin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Reduced efficacy of OCP

5. Unable to copy of matchstick - unable to dress up
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Verapamil
Construction apraxia; lesion in non dominant parietal lobe (right)
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

6. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Clonidine will take care both high bp and withdrawal

7. dementia plus urinary incontinence
Distal lower motor neuron disease
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
Normal pressure hydrocephalus

8. acoustic neuroma
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Despite the term neuroma they arise from schwann cells - schwanoma

9. what drug is used to extend effects of levodopa
Lesion in nondominant temporal lobe
Entacapone - COMT inhibitor
Aspirin - control HTN and swallow eval before giving any oral meds
Obturator n lesion

10. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Gilberts disease
Femoral n lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
20%

11. earliest sign of phenytoin toxicity
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
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Nystagmus on far lateral gaze

12. labyrinthitis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
82% specific for dementia

13. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
90% of right handed and 60% of left handed persons; speech and language function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

14. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Corticosteroid and acyclovir
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Upright supine position
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

15. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Get up from chair walk a short distance turn around and sit; screening test for fall
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
High dose IV methyleprednisone;

16. When to suspect traumatic LP
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
It patient has electrolyte imbalance and hypothermia
Difficulty in writing - calculating - distinguishing left and write
RBC count >6000

17. infections in GBS
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Clonidine will take care both high bp and withdrawal
EPV - campylobacter - HSV

18. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

19. oligoclonal band in CSF
Taper gradually to prevent seizure relapse
MS
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
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

20. prodrome of vasovagal syncope
Clonidine will take care both high bp and withdrawal
Taper gradually to prevent seizure relapse
Coronary artery disease
Tunnel vision - diaphoresis - nausea - pallor

21. How to manage stroke patient came within 4 hours
Botulism has descending paralysis in contrast othere have ascending paralysis
RBC count >6000
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
EPV - campylobacter - HSV

22. contraindication of sumatripta
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Coronary artery disease

23. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
<20; if patient scores >25 benign forgetfulness
Autospy gold standard
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
20%

24. benign essential tremor
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
82% specific for dementia

25. medial thigh sensory loss and weakness in addcution
20%
Obturator n lesion
Difficulty in writing - calculating - distinguishing left and write
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

26. How to tx stroke patient came after 6h
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
Entacapone - COMT inhibitor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

27. How to differentiate medial and lateral medullary syndrome
Aphasia - neglect - agnosia - acalculia etc
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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;
Nystagmus on far lateral gaze

28. MMSE score of less than 24
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
82% specific for dementia
Nystagmus on far lateral gaze
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

29. When headache is presenting complaint of brain tumor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Reduced efficacy of OCP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

30. korsafoff psychosis
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
Cholinesterase inhibitor; and antiparkinsonism drugs
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

31. impaired vibration and increased DTR
Diabetes insipidus
Not within 24 hours; give afte 24-48 hours if patient stable
Vitamin B12 deficiency
Spastic paraparesis

32. Tx of bells palsy
Corticosteroid and acyclovir
Verapamil
Cerebral palsy; dx mri
Cerebellar lesion

33. differentiate wenicke and korsakoff
Difficulty in writing - calculating - distinguishing left and write
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Follows viral illness; vertigo - tinnitus - nausea. self limiting

34. What is pronator drift
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
Spontaneous remission; admit if suspected and monitor pulse ox for 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
Nystagmus on far lateral gaze

35. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

36. Blood transfusion in hypothermia
Propranolol or primidone
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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.
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

37. differentiate lewy body dementia and vascular dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Upright supine position
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

38. How to differentiate dementias
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
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.

39. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Spastic paraparesis
Antitoxin
EPV - campylobacter - HSV

40. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cerebral palsy; dx mri
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

41. impaired hepatic conjugation of billirubin
Deficit in cranial nerve function
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Taper gradually to prevent seizure relapse
Gilberts disease

42. Tx of GBS
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Nystagmus on far lateral gaze

43. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Acetylecholinersterase inhibitors
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

44. anerior and anteriomedial thigh paresthesia - decreased DTR
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Femoral n lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

45. brain stem lesion
Deficit in cranial nerve function
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
IVIG and plasmapheresis
Antitoxin

46. indication of plasmapheresis in GBS
Tunnel vision - diaphoresis - nausea - pallor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Botulism has descending paralysis in contrast othere have ascending paralysis

47. 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.
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in writing - calculating - distinguishing left and write

48. cluster headache
<20; if patient scores >25 benign forgetfulness
IVIG and plasmapheresis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

49. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Obturator n lesion
82% specific for dementia

50. craniopharyngioma
Diabetes insipidus
Tunnel vision - diaphoresis - nausea - pallor
Clonidine will take care both high bp and withdrawal
Deficit in cranial nerve function