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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. What bp med to be given in a patient with high bp and signs of opioid withdrawal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Clonidine will take care both high bp and withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Tunnel vision - diaphoresis - nausea - pallor

2. How to manage stroke patient came within 4 hours
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.
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Propranolol or primidone

3. When headache is presenting complaint of brain tumor
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

4. How to differentiate botulism from tick born paralysis - GBS and MG
Autospy gold standard
Botulism has descending paralysis in contrast othere have ascending paralysis
Antitoxin
Entacapone - COMT inhibitor

5. lesion in dominant parietal lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Verapamil
Difficulty in writing - calculating - distinguishing left and write

6. impaired vibration and increased DTR
Vitamin B12 deficiency
High dose IV methyleprednisone;
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

7. MG
Taper gradually to prevent seizure relapse
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
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;
Acetylecholinersterase inhibitors

8. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Reduced efficacy of OCP

9. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
<20; if patient scores >25 benign forgetfulness
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

10. labyrinthitis
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
Cerebellar lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Taper gradually to prevent seizure relapse

11. phenytoin and OCP
Reduced efficacy of OCP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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;

12. double vision at the end of day and ptosis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Myasthenia; due to autoantibodies against acetylecholine receptor;

13. anerior and anteriomedial thigh paresthesia - decreased DTR
High dose IV methyleprednisone;
Femoral n lesion
It patient has electrolyte imbalance and hypothermia
RBC count >6000

14. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Distal lower motor neuron 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.

15. earliest sign of phenytoin toxicity
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Nystagmus on far lateral gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

16. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis
Upright supine position
<20; if patient scores >25 benign forgetfulness

17. When to use brain spect scintigraphy to confirm brain death
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
It patient has electrolyte imbalance and hypothermia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Verapamil

18. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Distal lower motor neuron disease
Gilberts disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

19. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Taper gradually to prevent seizure relapse
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

20. infections in GBS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
EPV - campylobacter - HSV
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;

21. MMSE score of less than 24
RBC count >6000
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
82% specific for dementia
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;

22. korsafoff psychosis
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.
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebellar lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

23. differentiate picks and huntington
Upright supine position
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
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. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Upright supine position
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
82% specific for dementia

25. women with unilateral eye pain; neurlogic symptoms here there at different times
It patient has electrolyte imbalance and hypothermia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Upright supine position
Lesion in nondominant temporal lobe

26. impaired perception of complex sounds
Lesion in nondominant temporal lobe
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
Distal lower motor neuron disease
Verapamil

27. what drug is used to extend effects of levodopa
Verapamil
Obturator n lesion
Entacapone - COMT inhibitor
Spastic paraparesis

28. stroke with lower facial palsy - pronator drift despite on aspirin
Cerebellar lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

29. lesion in dominant tempora lobe
20%
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
Aphasia - neglect - agnosia - acalculia etc

30. When to use dopamine agonist pramipexol in parkinson
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Aphasia - neglect - agnosia - acalculia etc

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

32. differentiate lewy body dementia and vascular dementia
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
Nystagmus on far lateral gaze
Cerebral palsy; dx mri
Spastic paraparesis

33. Why V12 deficient develop hypokalemia after tx with b12
Upright supine position
Lesion in nondominant temporal lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
90% of right handed and 60% of left handed persons; speech and language function

34. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in writing - calculating - distinguishing left and write
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

35. brain stem lesion
Aphasia - neglect - agnosia - acalculia etc
Deficit in cranial nerve function
Acetylecholinersterase inhibitors
Reduced efficacy of OCP

36. cortical 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
IVIG and plasmapheresis
Entacapone - COMT inhibitor
Aphasia - neglect - agnosia - acalculia etc

37. differentiate wenicke and korsakoff
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Gilberts disease
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

38. cluster headache
Diabetes insipidus
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
High dose IV methyleprednisone;
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

39. contraindication of sumatripta
Nystagmus on far lateral gaze
Coronary artery disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
IVIG and plasmapheresis
Femoral n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

41. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Diabetes insipidus
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
It patient has electrolyte imbalance and hypothermia
RBC count >6000

42. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Reduced efficacy of OCP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

43. impaired hepatic conjugation of billirubin
Gilberts disease
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Femoral n lesion

44. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Corticosteroid and acyclovir
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

45. botulism
Propranolol or primidone
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

46. Should we tx htn in acute ischemic stroke

47. Blood transfusion in hypothermia
It patient has electrolyte imbalance and hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Coronary artery disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

48. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

49. dementia plus urinary incontinence
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;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acetylecholinersterase inhibitors
Normal pressure hydrocephalus

50. best diagnosis for parkinsonim
<20; if patient scores >25 benign forgetfulness
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS