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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. Should we tx htn in acute ischemic stroke

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2. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Propranolol or primidone
IVIG and plasmapheresis

3. impaired vibration and increased DTR
Obturator n lesion
Femoral n lesion
Vitamin B12 deficiency
Coronary artery disease

4. anerior and anteriomedial thigh paresthesia - decreased DTR
Deficit in cranial nerve function
Femoral n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
EPV - campylobacter - HSV

5. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
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

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

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7. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Get up from chair walk a short distance turn around and sit; screening test for fall
Spastic paraparesis
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

8. benign essential tremor
Gilberts disease
Cerebral palsy; dx mri
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
Propranolol or primidone

9. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Upright supine position
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

10. prodrome of vasovagal syncope
Get up from chair walk a short distance turn around and sit; screening test for fall
Not within 24 hours; give afte 24-48 hours if patient stable
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
Tunnel vision - diaphoresis - nausea - pallor

11. How to differentiate medial and lateral pontine syndrome
Aphasia - neglect - agnosia - acalculia etc
Nystagmus on far lateral gaze
20%
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

12. When headache is presenting complaint of brain tumor
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
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

13. differentiate lewy body dementia and vascular dementia
Get up from chair walk a short distance turn around and sit; screening test for fall
90% of right handed and 60% of left handed persons; speech and language function
<20; if patient scores >25 benign forgetfulness
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

14. How to differentiate dementias
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Coronary artery disease

15. phenytoin and OCP
Tunnel vision - diaphoresis - nausea - pallor
Reduced efficacy of OCP
Lesion in nondominant temporal lobe
Nystagmus on far lateral gaze

16. labyrinthitis
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

17. When to start fibrinolytic therapy in stroke patient?
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

18. How to differentiate traumatic LP and SAH
Corticosteroid and acyclovir
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
EPV - campylobacter - HSV
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

19. severe headache and high BP
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
Difficulty in writing - calculating - distinguishing left and write
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

20. lesion in dominant tempora lobe
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Corticosteroid and acyclovir
Aphasia - neglect - agnosia - acalculia etc

21. medial thigh sensory loss and weakness in addcution
Acetylecholinersterase inhibitors
Obturator n lesion
Upright supine position
High dose IV methyleprednisone;

22. How to prevent prevent frequency of MS exacerbation
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Normal pressure hydrocephalus
Femoral n lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

23. oligoclonal band in CSF
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MS
High dose IV methyleprednisone;
Autospy gold standard

24. brain stem lesion
Deficit in cranial nerve function
Antitoxin
Nystagmus on far lateral gaze
Cholinesterase inhibitor; and antiparkinsonism drugs

25. MMSE score of less than 24
Cerebellar lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
82% specific for dementia
Get up from chair walk a short distance turn around and sit; screening test for fall

26. When to give aspirin when patient on tPA after stroke
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

27. stroke with lower facial palsy - pronator drift despite on aspirin
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Antitoxin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

28. Acute onset of left arm weakness
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
Normal pressure hydrocephalus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

29. contraindication of sumatripta
Coronary artery disease
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

30. How to manage stroke patient came within 4 hours
Cholinesterase inhibitor; and antiparkinsonism drugs
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Aphasia - neglect - agnosia - acalculia etc

31. double vision at the end of day and ptosis
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Myasthenia; due to autoantibodies against acetylecholine receptor;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

32. What is can be used cluster headache prevention
RBC count >6000
Lesion in nondominant temporal lobe
High dose IV methyleprednisone;
Verapamil

33. what drug is used to extend effects of levodopa
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Upright supine position
Entacapone - COMT inhibitor
82% specific for dementia

34. dominant parietal lobe on the left side
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors
Coronary artery disease
90% of right handed and 60% of left handed persons; speech and language function

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

36. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spastic paraparesis
Acetylecholinersterase inhibitors
Cholinesterase inhibitor; and antiparkinsonism drugs

37. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
RBC count >6000
Antitoxin
Cerebellar lesion
Botulism has descending paralysis in contrast othere have ascending paralysis

38. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus

39. cluster headache
Aphasia - neglect - agnosia - acalculia etc
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. What percent of dementia is reversible
Diabetes insipidus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
20%
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;

41. Why V12 deficient develop hypokalemia after tx with b12
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
High dose IV methyleprednisone;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

42. How to tx lewy body dementia
Propranolol or primidone
Cholinesterase inhibitor; and antiparkinsonism drugs
Femoral n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

43. impaired hepatic conjugation of billirubin
Gilberts disease
Taper gradually to prevent seizure relapse
High dose IV methyleprednisone;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

44. Blood transfusion in hypothermia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Entacapone - COMT inhibitor
Femoral n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

45. How to tx stroke patient came after 6h
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
Aphasia - neglect - agnosia - acalculia etc
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

46. How to differentiate parkinson and benign essential tremor
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
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
Get up from chair walk a short distance turn around and sit; screening test for fall
Follows viral illness; vertigo - tinnitus - nausea. self limiting

47. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Taper gradually to prevent seizure relapse
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
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

48. How to confirm braindeath?
MS
Not within 24 hours; give afte 24-48 hours if patient stable
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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. women with unilateral eye pain; neurlogic symptoms here there at different times
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Wernicke's encephalopathy; due to thiamine definition; medical emergency
RBC count >6000
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

50. How to stop antiepileptic drugs
Vitamin B12 deficiency
Taper gradually to prevent seizure relapse
It patient has electrolyte imbalance and hypothermia
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