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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. How to manage stroke patient came within 4 hours
Construction apraxia; lesion in non dominant parietal lobe (right)
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Entacapone - COMT inhibitor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

2. When to suspect traumatic LP
EPV - campylobacter - HSV
Botulism has descending paralysis in contrast othere have ascending paralysis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
RBC count >6000

3. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Antitoxin
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Femoral n lesion

4. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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;
It patient has electrolyte imbalance and hypothermia

5. oligoclonal band in CSF
Despite the term neuroma they arise from schwann cells - schwanoma
MS
Aspirin - control HTN and swallow eval before giving any oral meds
Gilberts disease

6. get up and go test
Construction apraxia; lesion in non dominant parietal lobe (right)
Get up from chair walk a short distance turn around and sit; screening test for fall
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

7. brain stem lesion
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Antitoxin
Deficit in cranial nerve function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

8. lesion in dominant parietal lobe
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Verapamil
Difficulty in writing - calculating - distinguishing left and write
Upright supine position

9. What mmse score suggest dementia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
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.

10. stroke with lower facial palsy - pronator drift despite on aspirin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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. Tx of GBS
EPV - campylobacter - HSV
Reduced efficacy of OCP
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Not within 24 hours; give afte 24-48 hours if patient stable

12. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position

13. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
It patient has electrolyte imbalance and hypothermia
Lesion in nondominant temporal lobe
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

14. How to differentiate parkinson and benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Deficit in cranial nerve function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

15. botulism
Antitoxin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV

16. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Lesion in nondominant temporal lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS

17. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Get up from chair walk a short distance turn around and sit; screening test for fall
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

18. What is pronator drift
Cerebellar lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Lesion in nondominant temporal lobe

19. Blood transfusion in hypothermia
Coronary artery disease
Cerebellar lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in writing - calculating - distinguishing left and write

20. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Lesion in nondominant temporal lobe
Upright supine position
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

21. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

22. anerior and anteriomedial thigh paresthesia - decreased DTR
Antitoxin
Femoral n lesion
Acetylecholinersterase inhibitors
Tunnel vision - diaphoresis - nausea - pallor

23. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Femoral n lesion
Acetylecholinersterase inhibitors
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

24. Why V12 deficient develop hypokalemia after tx with b12
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Propranolol or primidone
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

25. labyrinthitis
Clonidine will take care both high bp and withdrawal
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

26. When to give aspirin when patient on tPA after stroke
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Not within 24 hours; give afte 24-48 hours if patient stable
Get up from chair walk a short distance turn around and sit; screening test for fall
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

27. MMSE score of less than 24
Femoral n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia

28. differentiate wenicke and korsakoff
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
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
Normal pressure hydrocephalus
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

29. cluster headache
Corticosteroid and acyclovir
Upright supine position
90% of right handed and 60% of left handed persons; speech and language function
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

30. 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
Difficulty in writing - calculating - distinguishing left and write
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Reduced efficacy of OCP

31. 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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spastic paraparesis

32. prodrome of vasovagal syncope
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
Entacapone - COMT inhibitor
Tunnel vision - diaphoresis - nausea - pallor

33. When headache is presenting complaint of brain tumor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

34. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Aspirin - control HTN and swallow eval before giving any oral meds
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

35. How to tx lewy body dementia
Despite the term neuroma they arise from schwann cells - schwanoma
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
EPV - campylobacter - HSV
Cholinesterase inhibitor; and antiparkinsonism drugs

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

37. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Distal lower motor neuron disease
82% specific for dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

38. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Construction apraxia; lesion in non dominant parietal lobe (right)
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
EPV - campylobacter - HSV

39. How to prevent prevent frequency of MS exacerbation
20%
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

40. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Coronary artery disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

41. dementia plus urinary incontinence
Normal pressure hydrocephalus
Cholinesterase inhibitor; and antiparkinsonism drugs
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

42. phenytoin and OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Reduced efficacy of OCP
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

43. GBS
IVIG and plasmapheresis
RBC count >6000
Distal lower motor neuron disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

44. impaired hepatic conjugation of billirubin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Gilberts disease
Cerebral palsy; dx mri
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

45. When to use dopamine agonist pramipexol in parkinson
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebral palsy; dx mri

46. How to differentiate medial and lateral pontine syndrome
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
MS
Cerebral palsy; dx mri
IVIG and plasmapheresis

47. benign essential tremor
Nystagmus on far lateral gaze
Propranolol or primidone
IVIG and plasmapheresis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

48. at first tingling in toes and feet then weakness in extremities
IVIG and plasmapheresis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Vitamin B12 deficiency
Verapamil

49. infections in GBS
EPV - campylobacter - HSV
Cerebral palsy; dx mri
RBC count >6000
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

50. dominant parietal lobe on the left side
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
90% of right handed and 60% of left handed persons; speech and language function
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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