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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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
It patient has electrolyte imbalance and hypothermia
Corticosteroid and acyclovir

2. cortical lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

3. How to confirm braindeath?
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Vitamin B12 deficiency
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.
Propranolol or primidone

4. differentiate picks and huntington
Propranolol or primidone
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

5. When to use dopamine agonist pramipexol in parkinson
Not within 24 hours; give afte 24-48 hours if patient stable
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
IVIG and plasmapheresis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

6. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Propranolol or primidone
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebral palsy; dx mri

7. Patient with carbamazepine; What should be advice?
Entacapone - COMT inhibitor
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Lesion in nondominant temporal lobe

8. 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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

9. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Propranolol or primidone
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

10. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Tunnel vision - diaphoresis - nausea - pallor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

11. dementia plus urinary incontinence
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis
RBC count >6000
Normal pressure hydrocephalus

12. Tx of bells palsy
Deficit in cranial nerve function
Corticosteroid and acyclovir
Aphasia - neglect - agnosia - acalculia etc
Not within 24 hours; give afte 24-48 hours if patient stable

13. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Despite the term neuroma they arise from schwann cells - schwanoma
Aspirin - control HTN and swallow eval before giving any oral meds
It patient has electrolyte imbalance and hypothermia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

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

15. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebral palsy; dx mri
Myasthenia; due to autoantibodies against acetylecholine receptor;

16. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spastic paraparesis
82% specific for dementia
Aphasia - neglect - agnosia - acalculia etc

17. korsafoff psychosis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

18. phenytoin and OCP
Reduced efficacy of OCP
Lesion in nondominant temporal lobe
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

19. How to stop antiepileptic drugs
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
IVIG and plasmapheresis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

20. Blood transfusion in hypothermia
Propranolol or primidone
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
IVIG and plasmapheresis
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

21. what drug is used to extend effects of levodopa
RBC count >6000
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor
Follows viral illness; vertigo - tinnitus - nausea. self limiting

22. GBS
Cerebellar lesion
Femoral n lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
IVIG and plasmapheresis

23. How to differentiate traumatic LP and SAH
Acetylecholinersterase inhibitors
Vitamin B12 deficiency
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

24. infections in GBS
EPV - campylobacter - HSV
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

25. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aphasia - neglect - agnosia - acalculia etc
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

26. impaired vibration and increased DTR
Vitamin B12 deficiency
Cholinesterase inhibitor; and antiparkinsonism drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in writing - calculating - distinguishing left and write

27. indication of plasmapheresis in GBS
Entacapone - COMT inhibitor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Nystagmus on far lateral gaze
Obturator n lesion

28. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Distal lower motor neuron disease
Deficit in cranial nerve function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

29. How to differentiate parkinson and benign essential tremor
RBC count >6000
Cholinesterase inhibitor; and antiparkinsonism drugs
Entacapone - COMT inhibitor
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

30. How to tx acute exacerbation of MS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
High dose IV methyleprednisone;
Deficit in cranial nerve function
It patient has electrolyte imbalance and hypothermia

31. What percent of dementia is reversible
Construction apraxia; lesion in non dominant parietal lobe (right)
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Myasthenia; due to autoantibodies against acetylecholine receptor;
20%

32. 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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting

33. How to tx stroke patient came after 6h
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aspirin - control HTN and swallow eval before giving any oral meds

34. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Despite the term neuroma they arise from schwann cells - schwanoma
<20; if patient scores >25 benign forgetfulness
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

35. excessive elevation of legs during walking (toe touch floor earlier than heels)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
It patient has electrolyte imbalance and hypothermia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Distal lower motor neuron disease

36. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Deficit in cranial nerve function
82% specific for dementia
20%

37. contraindication of sumatripta
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Coronary artery disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
<20; if patient scores >25 benign forgetfulness

38. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
IVIG and plasmapheresis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

39. 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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
<20; if patient scores >25 benign forgetfulness
Deficit in cranial nerve function

40. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Normal pressure hydrocephalus
<20; if patient scores >25 benign forgetfulness
Cerebellar lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

41. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

42. When to use brain spect scintigraphy to confirm brain death
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

43. brain stem lesion
Femoral n lesion
Deficit in cranial nerve function
Construction apraxia; lesion in non dominant parietal lobe (right)
Botulism has descending paralysis in contrast othere have ascending paralysis

44. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Reduced efficacy of OCP

45. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Diabetes insipidus
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.

46. How to tx lewy body dementia
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
Upright supine position
Cholinesterase inhibitor; and antiparkinsonism drugs

47. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
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;
90% of right handed and 60% of left handed persons; speech and language function

48. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Get up from chair walk a short distance turn around and sit; screening test for fall
90% of right handed and 60% of left handed persons; speech and language function
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

49. How to differentiate medial and lateral medullary syndrome
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;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Construction apraxia; lesion in non dominant parietal lobe (right)
Antitoxin

50. Should we tx htn in acute ischemic stroke