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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. anerior and anteriomedial thigh paresthesia - decreased DTR
90% of right handed and 60% of left handed persons; speech and language function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
High dose IV methyleprednisone;
Femoral n lesion

2. How to stop antiepileptic drugs
Diabetes insipidus
RBC count >6000
Taper gradually to prevent seizure relapse
Distal lower motor neuron disease

3. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

4. 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
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
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

5. How to tx lewy body dementia
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Normal pressure hydrocephalus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

6. infections in GBS
Cerebral palsy; dx mri
EPV - campylobacter - HSV
IVIG and plasmapheresis
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

7. How to differentiate dementias
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Antitoxin
Diabetes insipidus

8. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Normal pressure hydrocephalus

9. What percent of dementia is reversible
20%
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
Autospy gold standard
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

10. acoustic neuroma
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Despite the term neuroma they arise from schwann cells - schwanoma
Corticosteroid and acyclovir

11. Should we tx htn in acute ischemic stroke

12. GBS
High dose IV methyleprednisone;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
IVIG and plasmapheresis
Vitamin B12 deficiency

13. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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

14. What is pronator drift
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

15. double vision at the end of day and ptosis
90% of right handed and 60% of left handed persons; speech and language function
Verapamil
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

16. craniopharyngioma
Diabetes insipidus
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Not within 24 hours; give afte 24-48 hours if patient stable
Acetylecholinersterase inhibitors

17. MG
Entacapone - COMT inhibitor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
RBC count >6000
Acetylecholinersterase inhibitors

18. medial thigh sensory loss and weakness in addcution
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS
Nystagmus on far lateral gaze
Obturator n lesion

19. cluster headache
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
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

20. 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;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Botulism has descending paralysis in contrast othere have ascending paralysis
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

21. differentiate lewy body dementia and vascular dementia
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
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
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

22. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

23. How to perform apnea test
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
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

24. Acute onset of left arm weakness
82% specific for dementia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

25. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Lesion in nondominant temporal lobe
Distal lower motor neuron disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

26. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Acetylecholinersterase inhibitors
Verapamil
Tunnel vision - diaphoresis - nausea - pallor

27. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aphasia - neglect - agnosia - acalculia etc
Difficulty in writing - calculating - distinguishing left and write
Coronary artery disease

28. When to suspect traumatic LP
Corticosteroid and acyclovir
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Gilberts disease
RBC count >6000

29. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

30. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

31. How to manage stroke patient came within 4 hours
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

32. prodrome of vasovagal syncope
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor
<20; if patient scores >25 benign forgetfulness
Upright supine position

33. excessive elevation of legs during walking (toe touch floor earlier than heels)
Autospy gold standard
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
Distal lower motor neuron disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

34. benign essential tremor
Propranolol or primidone
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
RBC count >6000
Acetylecholinersterase inhibitors

35. botulism
Difficulty in writing - calculating - distinguishing left and write
Antitoxin
Entacapone - COMT inhibitor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

36. Why V12 deficient develop hypokalemia after tx with b12
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

37. What is can be used cluster headache prevention
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Verapamil
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
Normal pressure hydrocephalus

38. How to prevent prevent frequency of MS exacerbation
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

39. Blood transfusion in hypothermia
Entacapone - COMT inhibitor
Not within 24 hours; give afte 24-48 hours if patient stable
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

40. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Despite the term neuroma they arise from schwann cells - schwanoma
Vitamin B12 deficiency
MS

41. Unable to copy of matchstick - unable to dress up
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

42. oligoclonal band in CSF
MS
Autospy gold standard
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.
IVIG and plasmapheresis

43. impaired vibration and increased DTR
Vitamin B12 deficiency
High dose IV methyleprednisone;
Distal lower motor neuron disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

44. phenytoin and OCP
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
Reduced efficacy of OCP
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
Cerebral palsy; dx mri

45. Tx of bells palsy
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
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
Corticosteroid and acyclovir

46. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Cholinesterase inhibitor; and antiparkinsonism drugs
Clonidine will take care both high bp and withdrawal
Construction apraxia; lesion in non dominant parietal lobe (right)

47. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Get up from chair walk a short distance turn around and sit; screening test for fall
MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

48. How to tx stroke patient came after 6h
Verapamil
Aspirin - control HTN and swallow eval before giving any oral meds
Cholinesterase inhibitor; and antiparkinsonism drugs
High dose IV methyleprednisone;

49. get up and go test
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Get up from chair walk a short distance turn around and sit; screening test for fall
Aphasia - neglect - agnosia - acalculia etc
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

50. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Despite the term neuroma they arise from schwann cells - schwanoma
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