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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. at first tingling in toes and feet then weakness in extremities
Aphasia - neglect - agnosia - acalculia etc
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Antitoxin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

2. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

3. How to confirm braindeath?
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
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.

4. anerior and anteriomedial thigh paresthesia - decreased DTR
Cholinesterase inhibitor; and antiparkinsonism drugs
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Femoral n lesion

5. What is pronator drift
Vitamin B12 deficiency
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

6. labyrinthitis
Clonidine will take care both high bp and withdrawal
Upright supine position
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone

7. How to differentiate traumatic LP and SAH
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
Cerebellar lesion
Antitoxin

8. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Verapamil
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

9. severe headache and high BP
Cholinesterase inhibitor; and antiparkinsonism drugs
Diabetes insipidus
Femoral n lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

10. earliest sign of phenytoin toxicity
Vitamin B12 deficiency
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
Nystagmus on far lateral gaze

11. How to prevent prevent frequency of MS exacerbation
Construction apraxia; lesion in non dominant parietal lobe (right)
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.
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

12. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cerebellar lesion
Upright supine position

13. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Difficulty in writing - calculating - distinguishing left and write
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

14. differentiate lewy body dementia and vascular dementia
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
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
Cerebellar lesion

15. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Femoral n lesion
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

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

17. acoustic neuroma
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Despite the term neuroma they arise from schwann cells - schwanoma
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aspirin - control HTN and swallow eval before giving any oral meds

18. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Propranolol or primidone
Verapamil

19. Should we tx htn in acute ischemic stroke

20. craniopharyngioma
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Clonidine will take care both high bp and withdrawal

21. botulism
Antitoxin
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;
Cerebellar lesion
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

22. women with unilateral eye pain; neurlogic symptoms here there at different times
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000
Coronary artery disease
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

23. impaired hepatic conjugation of billirubin
Corticosteroid and acyclovir
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis

24. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs
90% of right handed and 60% of left handed persons; speech and language function
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

25. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in writing - calculating - distinguishing left and write
Construction apraxia; lesion in non dominant parietal lobe (right)
Distal lower motor neuron disease

26. How to tx acute exacerbation of MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Femoral n lesion
High dose IV methyleprednisone;

27. brain stem lesion
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
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
Deficit in cranial nerve function

28. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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.

29. impaired perception of complex sounds
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe

30. When to use dopamine agonist pramipexol in parkinson
Taper gradually to prevent seizure relapse
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in writing - calculating - distinguishing left and write

31. infections in GBS
Despite the term neuroma they arise from schwann cells - schwanoma
Aspirin - control HTN and swallow eval before giving any oral meds
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
EPV - campylobacter - HSV

32. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Tunnel vision - diaphoresis - nausea - pallor
Construction apraxia; lesion in non dominant parietal lobe (right)
Cerebellar lesion

33. What mmse score suggest dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
<20; if patient scores >25 benign forgetfulness
20%
Cerebellar lesion

34. How to tx lewy body dementia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Cholinesterase inhibitor; and antiparkinsonism drugs
Autospy gold standard
Deficit in cranial nerve function

35. cluster headache
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
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
EPV - campylobacter - HSV
90% of right handed and 60% of left handed persons; speech and language function

36. lesion in dominant tempora lobe
Lesion in nondominant temporal lobe
Cholinesterase inhibitor; and antiparkinsonism drugs
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Normal pressure hydrocephalus

37. best diagnosis for parkinsonim
Get up from chair walk a short distance turn around and sit; screening test for fall
20%
Autospy gold standard
Antitoxin

38. stroke with lower facial palsy - pronator drift despite on aspirin
It patient has electrolyte imbalance and hypothermia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Reduced efficacy of OCP
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

39. How to differentiate medial and lateral pontine syndrome
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
Normal pressure hydrocephalus
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
Botulism has descending paralysis in contrast othere have ascending paralysis

40. How to perform apnea test
Vitamin B12 deficiency
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Diabetes insipidus

41. differentiate picks and huntington
Aspirin - control HTN and swallow eval before giving any oral meds
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

42. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Gilberts disease
82% specific for dementia
Cerebral palsy; dx mri
Antitoxin

43. Blood transfusion in hypothermia
Diabetes insipidus
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

44. medial thigh sensory loss and weakness in addcution
EPV - campylobacter - HSV
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Obturator n lesion

45. 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;
Verapamil
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

46. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Taper gradually to prevent seizure relapse
20%
Tunnel vision - diaphoresis - nausea - pallor
Spastic paraparesis

47. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebellar lesion
Lesion in nondominant temporal lobe
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

48. Unable to copy of matchstick - unable to dress up
Clonidine will take care both high bp and withdrawal
IVIG and plasmapheresis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Construction apraxia; lesion in non dominant parietal lobe (right)

49. Tx of bells palsy
Corticosteroid and acyclovir
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

50. benign essential tremor
Botulism has descending paralysis in contrast othere have ascending paralysis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MS
Propranolol or primidone