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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. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Clonidine will take care both high bp and withdrawal
Botulism has descending paralysis in contrast othere have ascending paralysis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

2. cortical lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Aphasia - neglect - agnosia - acalculia etc
Deficit in cranial nerve function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

3. How to tx lewy body 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.
Aspirin - control HTN and swallow eval before giving any oral meds
20%
Cholinesterase inhibitor; and antiparkinsonism drugs

4. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Coronary artery disease
Entacapone - COMT inhibitor
Distal lower motor neuron disease

5. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
90% of right handed and 60% of left handed persons; speech and language function
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
Upright supine position
Myasthenia; due to autoantibodies against acetylecholine receptor;

6. How to differentiate parkinson and benign essential tremor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Aspirin - control HTN and swallow eval before giving any oral meds
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

7. What percent of dementia is reversible
20%
Myasthenia; due to autoantibodies against acetylecholine receptor;
90% of right handed and 60% of left handed persons; speech and language function
Botulism has descending paralysis in contrast othere have ascending paralysis

8. Patient with carbamazepine; What should be advice?
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
RBC count >6000
Reduced efficacy of OCP

9. get up and go test
Obturator n lesion
Acetylecholinersterase inhibitors
Get up from chair walk a short distance turn around and sit; screening test for fall
EPV - campylobacter - HSV

10. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Reduced efficacy of OCP
High dose IV methyleprednisone;

11. impaired perception of complex sounds
Lesion in nondominant temporal lobe
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
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

12. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Aspirin - control HTN and swallow eval before giving any oral meds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

13. contraindication of sumatripta
Vitamin B12 deficiency
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Coronary artery disease
82% specific for dementia

14. earliest sign of phenytoin toxicity
Normal pressure hydrocephalus
Nystagmus on far lateral gaze
Lesion in nondominant temporal lobe
Taper gradually to prevent seizure relapse

15. GBS
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
IVIG and plasmapheresis

16. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Diabetes insipidus
Difficulty in writing - calculating - distinguishing left and write

17. How to prevent prevent frequency of MS exacerbation
Aspirin - control HTN and swallow eval before giving any oral meds
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000

18. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Antitoxin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cerebral palsy; dx mri

19. How to tx acute exacerbation of MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Autospy gold standard
High dose IV methyleprednisone;
<20; if patient scores >25 benign forgetfulness

20. When to use brain spect scintigraphy to confirm brain death
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Distal lower motor neuron disease
It patient has electrolyte imbalance and hypothermia
Get up from chair walk a short distance turn around and sit; screening test for fall

21. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

22. How to differentiate medial and lateral medullary syndrome
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebellar lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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;

23. How to manage stroke patient came within 4 hours
Lesion in nondominant temporal lobe
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Femoral n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

24. severe headache and high BP
Construction apraxia; lesion in non dominant parietal lobe (right)
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

25. Should we tx htn in acute ischemic stroke

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26. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Cerebellar lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

27. craniopharyngioma
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
Despite the term neuroma they arise from schwann cells - schwanoma
Diabetes insipidus
EPV - campylobacter - HSV

28. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Cerebral palsy; dx mri

29. impaired vibration and increased DTR
Entacapone - COMT inhibitor
Difficulty in writing - calculating - distinguishing left and write
Vitamin B12 deficiency
IVIG and plasmapheresis

30. stroke with lower facial palsy - pronator drift despite on aspirin
Deficit in cranial nerve function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
It patient has electrolyte imbalance and hypothermia
Tunnel vision - diaphoresis - nausea - pallor

31. oligoclonal band in CSF
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS
Reduced efficacy of OCP
IVIG and plasmapheresis

32. lesion in dominant parietal lobe
IVIG and plasmapheresis
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in writing - calculating - distinguishing left and write
Follows viral illness; vertigo - tinnitus - nausea. self limiting

33. brain stem lesion
Deficit in cranial nerve function
EPV - campylobacter - HSV
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

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

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35. Blood transfusion in hypothermia
IVIG and plasmapheresis
20%
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Femoral n lesion

36. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
90% of right handed and 60% of left handed persons; speech and language function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Get up from chair walk a short distance turn around and sit; screening test for fall

37. dominant parietal lobe on the left side
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
90% of right handed and 60% of left handed persons; speech and language function
Construction apraxia; lesion in non dominant parietal lobe (right)

38. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

39. How to differentiate traumatic LP and SAH
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Normal pressure hydrocephalus

40. lesion in dominant tempora lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

41. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
RBC count >6000
Diabetes insipidus
It patient has electrolyte imbalance and hypothermia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

42. double vision at the end of day and ptosis
Taper gradually to prevent seizure relapse
Myasthenia; due to autoantibodies against acetylecholine receptor;
High dose IV methyleprednisone;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

43. How to confirm braindeath?
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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.
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebral palsy; dx mri

44. How to stop antiepileptic drugs
Autospy gold standard
Taper gradually to prevent seizure relapse
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
Despite the term neuroma they arise from schwann cells - schwanoma

45. When to suspect traumatic LP
Difficulty in writing - calculating - distinguishing left and write
Cerebellar lesion
20%
RBC count >6000

46. What is can be used cluster headache prevention
Verapamil
MS
Botulism has descending paralysis in contrast othere have ascending paralysis
Tunnel vision - diaphoresis - nausea - pallor

47. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Femoral n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acetylecholinersterase inhibitors

48. medial thigh sensory loss and weakness in addcution
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Obturator n lesion
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

49. Why V12 deficient develop hypokalemia after tx with b12
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
Difficulty in writing - calculating - distinguishing left and write
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Botulism has descending paralysis in contrast othere have ascending paralysis

50. women with unilateral eye pain; neurlogic symptoms here there at different times
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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.
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS