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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. 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
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.
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
20%

2. infections in GBS
EPV - campylobacter - HSV
82% specific for dementia
It patient has electrolyte imbalance and hypothermia
Gilberts disease

3. prodrome of vasovagal syncope
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze
Tunnel vision - diaphoresis - nausea - pallor
MS

4. What is pronator drift
Coronary artery disease
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
Not within 24 hours; give afte 24-48 hours if patient stable
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

5. Unable to copy of matchstick - unable to dress up
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Construction apraxia; lesion in non dominant parietal lobe (right)
20%
Aspirin - control HTN and swallow eval before giving any oral meds

6. acoustic neuroma
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.
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
EPV - campylobacter - HSV

7. Tx of bells palsy
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in writing - calculating - distinguishing left and write
IVIG and plasmapheresis
Corticosteroid and acyclovir

8. differentiate wenicke and 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
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Distal lower motor neuron disease

9. How to differentiate medial and lateral medullary syndrome
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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;

10. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Reduced efficacy of OCP

11. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Vitamin B12 deficiency
Upright supine position
Entacapone - COMT inhibitor

12. indication of plasmapheresis in GBS
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.
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;

13. When to use dopamine agonist pramipexol in parkinson
High dose IV methyleprednisone;
Nystagmus on far lateral gaze
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS

14. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cerebral palsy; dx mri

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

16. stroke with lower facial palsy - pronator drift despite on aspirin
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
Obturator n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

17. How to tx lewy body dementia
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Acetylecholinersterase inhibitors

18. lesion in dominant parietal lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Construction apraxia; lesion in non dominant parietal lobe (right)
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in writing - calculating - distinguishing left and write

19. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard

20. How to tx acute exacerbation of MS
RBC count >6000
High dose IV methyleprednisone;
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.
Cerebral palsy; dx mri

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

22. differentiate lewy body dementia and vascular dementia
Difficulty in writing - calculating - distinguishing left and write
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
Deficit in cranial nerve function
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

23. impaired hepatic conjugation of billirubin
Autospy gold standard
Botulism has descending paralysis in contrast othere have ascending paralysis
Gilberts disease
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

24. double vision at the end of day and ptosis
Cholinesterase inhibitor; and antiparkinsonism drugs
Myasthenia; due to autoantibodies against acetylecholine receptor;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

25. How to confirm braindeath?
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
MS
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.
Wernicke's encephalopathy; due to thiamine definition; medical emergency

26. Acute onset of left arm weakness
Autospy gold standard
Aphasia - neglect - agnosia - acalculia etc
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir

27. How to differentiate parkinson and benign essential tremor
Acetylecholinersterase inhibitors
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
Normal pressure hydrocephalus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

28. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Cerebellar lesion
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

29. at first tingling in toes and feet then weakness in extremities
Cerebral palsy; dx mri
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Normal pressure hydrocephalus

30. craniopharyngioma
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Propranolol or primidone
EPV - campylobacter - HSV
Diabetes insipidus

31. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

32. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Coronary artery disease
Distal lower motor neuron disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis

33. When headache is presenting complaint of brain tumor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Antitoxin

34. contraindication of sumatripta
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Coronary artery disease
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

35. Tx of GBS
Autospy gold standard
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
Difficulty in writing - calculating - distinguishing left and write
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

36. How to differentiate botulism from tick born paralysis - GBS and MG
Propranolol or primidone
Botulism has descending paralysis in contrast othere have ascending paralysis
82% specific for dementia
Difficulty in writing - calculating - distinguishing left and write

37. Should we tx htn in acute ischemic stroke

38. impaired perception of complex sounds
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Lesion in nondominant temporal lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Diabetes insipidus

39. GBS
IVIG and plasmapheresis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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.
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

40. How to stop antiepileptic drugs
82% specific for dementia
Taper gradually to prevent seizure relapse
Obturator n lesion
EPV - campylobacter - HSV

41. MMSE score of less than 24
Taper gradually to prevent seizure relapse
82% specific for dementia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Obturator n lesion

42. labyrinthitis
Nystagmus on far lateral gaze
It patient has electrolyte imbalance and hypothermia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV

43. What mmse score suggest dementia
Entacapone - COMT inhibitor
<20; if patient scores >25 benign forgetfulness
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

44. When to suspect traumatic LP
RBC count >6000
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Upright supine position

45. dementia plus urinary incontinence
Normal pressure hydrocephalus
Coronary artery disease
Propranolol or primidone
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

46. 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
Femoral n lesion
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Propranolol or primidone

47. How to manage stroke patient came within 4 hours
Vitamin B12 deficiency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
EPV - campylobacter - HSV

48. botulism
Get up from chair walk a short distance turn around and sit; screening test for fall
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Antitoxin

49. What percent of dementia is reversible
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
20%
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
Vitamin B12 deficiency

50. best diagnosis for parkinsonim
IVIG and plasmapheresis
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.
Autospy gold standard
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID