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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. benign essential tremor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Reduced efficacy of OCP
Normal pressure hydrocephalus
Propranolol or primidone

2. 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Construction apraxia; lesion in non dominant parietal lobe (right)

3. impaired vibration and increased DTR
Vitamin B12 deficiency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
MS

4. women with unilateral eye pain; neurlogic symptoms here there at different times
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

5. 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
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
Distal lower motor neuron disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

6. impaired hepatic conjugation of billirubin
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
High dose IV methyleprednisone;
Gilberts disease

7. infections in GBS
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
Acetylecholinersterase inhibitors
EPV - campylobacter - HSV
Vitamin B12 deficiency

8. How to tx lewy body dementia
Verapamil
Cholinesterase inhibitor; and antiparkinsonism drugs
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

9. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Acetylecholinersterase inhibitors

10. How to tx acute exacerbation of MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
High dose IV methyleprednisone;

11. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Nystagmus on far lateral gaze
Gilberts disease
Femoral n lesion

12. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;
Upright supine position
Cerebellar lesion

13. contraindication of sumatripta
Get up from chair walk a short distance turn around and sit; screening test for fall
82% specific for dementia
Gilberts disease
Coronary artery disease

14. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
It patient has electrolyte imbalance and hypothermia
Spastic paraparesis
Verapamil
Upright supine position

15. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
82% specific for dementia

16. impaired perception of complex sounds
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Lesion in nondominant temporal lobe
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

17. best diagnosis for parkinsonim
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Autospy gold standard
Vitamin B12 deficiency
Cerebellar lesion

18. get up and go test
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
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
Cerebral palsy; dx mri

19. When headache is presenting complaint of brain tumor
Difficulty in writing - calculating - distinguishing left and write
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Construction apraxia; lesion in non dominant parietal lobe (right)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

20. double vision at the end of day and ptosis
<20; if patient scores >25 benign forgetfulness
Myasthenia; due to autoantibodies against acetylecholine receptor;
Construction apraxia; lesion in non dominant parietal lobe (right)
Tunnel vision - diaphoresis - nausea - pallor

21. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Autospy gold standard
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

22. MG
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Corticosteroid and acyclovir
Acetylecholinersterase inhibitors

23. GBS
Construction apraxia; lesion in non dominant parietal lobe (right)
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
IVIG and plasmapheresis
Clonidine will take care both high bp and withdrawal

24. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Cholinesterase inhibitor; and antiparkinsonism drugs
Nystagmus on far lateral 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

25. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Propranolol or primidone
Cerebellar lesion
Femoral n lesion

26. 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
RBC count >6000
Taper gradually to prevent seizure relapse
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

27. Acute onset of left arm weakness
Taper gradually to prevent seizure relapse
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
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

28. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri

29. cluster headache
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Spastic paraparesis

30. earliest sign of phenytoin toxicity
Gilberts disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Nystagmus on far lateral gaze
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;

31. When to give aspirin when patient on tPA after stroke
Lesion in nondominant temporal lobe
Not within 24 hours; give afte 24-48 hours if patient stable
Cholinesterase inhibitor; and antiparkinsonism drugs
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

32. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebral palsy; dx mri
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

33. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acetylecholinersterase inhibitors
Obturator n lesion
Taper gradually to prevent seizure relapse

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

35. craniopharyngioma
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Diabetes insipidus

36. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Coronary artery disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

37. How to differentiate parkinson and benign essential tremor
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
20%
Cholinesterase inhibitor; and antiparkinsonism drugs

38. When to suspect traumatic LP
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Antitoxin
RBC count >6000

39. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds
Cholinesterase inhibitor; and antiparkinsonism drugs

40. stroke with lower facial palsy - pronator drift despite on aspirin
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

41. How to tx stroke patient came after 6h
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in writing - calculating - distinguishing left and write
Aspirin - control HTN and swallow eval before giving any oral meds
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

42. How to differentiate traumatic LP and SAH
Cerebellar lesion
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

43. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
EPV - campylobacter - HSV
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Entacapone - COMT inhibitor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

44. oligoclonal band in CSF
Aspirin - control HTN and swallow eval before giving any oral meds
MS
82% specific for dementia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

45. 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
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
Distal lower motor neuron disease
Aspirin - control HTN and swallow eval before giving any oral meds

46. what drug is used to extend effects of levodopa
Not within 24 hours; give afte 24-48 hours if patient stable
Reduced efficacy of OCP
Distal lower motor neuron disease
Entacapone - COMT inhibitor

47. When to use dopamine agonist pramipexol in parkinson
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

48. How to confirm braindeath?
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
Coronary artery disease
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.

49. How to differentiate dementias
Propranolol or primidone
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Distal lower motor neuron disease
Aspirin - control HTN and swallow eval before giving any oral meds

50. lesion in dominant tempora lobe
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening