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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. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Corticosteroid and acyclovir
Entacapone - COMT inhibitor
Cerebellar lesion
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

2. How to differentiate medial and lateral pontine syndrome
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
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Femoral n lesion

3. brain stem lesion
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
Gilberts disease
Cerebellar lesion
Deficit in cranial nerve function

4. MG
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Antitoxin
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acetylecholinersterase inhibitors

5. impaired perception of complex sounds
EPV - campylobacter - HSV
Lesion in nondominant temporal lobe
Tunnel vision - diaphoresis - nausea - pallor
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

6. differentiate picks and huntington
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Femoral n lesion

7. korsafoff psychosis
Verapamil
Spontaneous remission; admit if suspected and monitor pulse ox for 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
Acetylecholinersterase inhibitors

8. what drug is used to extend effects of levodopa
Get up from chair walk a short distance turn around and sit; screening test for fall
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Entacapone - COMT inhibitor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

9. benign essential tremor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
Nystagmus on far lateral gaze
Propranolol or primidone

10. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Obturator n lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
<20; if patient scores >25 benign forgetfulness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

11. How to differentiate dementias
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
82% specific for dementia
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

12. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Spontaneous remission; admit if suspected and monitor pulse ox for 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
Construction apraxia; lesion in non dominant parietal lobe (right)
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

13. craniopharyngioma
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Distal lower motor neuron disease
Diabetes insipidus
90% of right handed and 60% of left handed persons; speech and language function

14. get up and go test
Normal pressure hydrocephalus
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.
Get up from chair walk a short distance turn around and sit; screening test for fall
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

15. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Diabetes insipidus
Antitoxin

16. How to differentiate parkinson and benign essential tremor
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
IVIG and plasmapheresis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

17. How to differentiate medial and lateral medullary syndrome
Vitamin B12 deficiency
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;
Antitoxin
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

18. impaired vibration and increased DTR
Distal lower motor neuron disease
Vitamin B12 deficiency
Construction apraxia; lesion in non dominant parietal lobe (right)
Verapamil

19. When to suspect traumatic LP
Propranolol or primidone
RBC count >6000
Obturator n lesion
High dose IV methyleprednisone;

20. Blood transfusion in hypothermia
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
IVIG and plasmapheresis
MS

21. contraindication of sumatripta
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in writing - calculating - distinguishing left and write
Coronary artery disease
Acetylecholinersterase inhibitors

22. MMSE score of less than 24
82% specific for dementia
<20; if patient scores >25 benign forgetfulness
Not within 24 hours; give afte 24-48 hours if patient stable
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

23. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Distal lower motor neuron disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

24. 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
Autospy gold standard
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

25. When headache is presenting complaint of brain tumor
90% of right handed and 60% of left handed persons; speech and language function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

26. lesion in dominant tempora lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Coronary artery disease
Nystagmus on far lateral gaze

27. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Verapamil
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

28. best diagnosis for parkinsonim
Corticosteroid and acyclovir
Cholinesterase inhibitor; and antiparkinsonism drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Autospy gold standard

29. Tx of bells palsy
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir
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

30. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Gilberts disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Deficit in cranial nerve function

31. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aspirin - control HTN and swallow eval before giving any oral meds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

32. labyrinthitis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting

33. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Deficit in cranial nerve function
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

34. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Deficit in cranial nerve function
Construction apraxia; lesion in non dominant parietal lobe (right)
MS

35. When to give aspirin when patient on tPA after stroke
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Not within 24 hours; give afte 24-48 hours if patient stable
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

36. What is can be used cluster headache prevention
Propranolol or primidone
20%
Verapamil
Aspirin - control HTN and swallow eval before giving any oral meds

37. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus

38. dementia plus urinary incontinence
MS
Difficulty in writing - calculating - distinguishing left and write
Normal pressure hydrocephalus
Tunnel vision - diaphoresis - nausea - pallor

39. Patient with carbamazepine; What should be advice?
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Nystagmus on far lateral gaze
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
Upright supine position

40. Should we tx htn in acute ischemic stroke

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41. phenytoin and OCP
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;
Reduced efficacy of OCP
Distal lower motor neuron disease
90% of right handed and 60% of left handed persons; speech and language function

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

43. When to start fibrinolytic therapy in stroke patient?
Deficit in cranial nerve function
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Gilberts disease

44. Why V12 deficient develop hypokalemia after tx with b12
Corticosteroid and acyclovir
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

45. prodrome of vasovagal syncope
Get up from chair walk a short distance turn around and sit; screening test for fall
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis
Antitoxin

46. double vision at the end of day and ptosis
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
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;

47. oligoclonal band in CSF
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS
Gilberts disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

48. How to tx lewy body dementia
Obturator n lesion
20%
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs

49. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Despite the term neuroma they arise from schwann cells - schwanoma

50. GBS
Reduced efficacy of OCP
RBC count >6000
IVIG and plasmapheresis
Femoral n lesion