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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. infections in GBS
EPV - campylobacter - HSV
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

2. cluster headache
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
Clonidine will take care both high bp and withdrawal
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

3. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebral palsy; dx mri
Cerebellar lesion
Verapamil
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

4. When to suspect traumatic LP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Distal lower motor neuron disease
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
RBC count >6000

5. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acetylecholinersterase inhibitors
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Upright supine position

6. How to tx acute exacerbation of MS
Cerebral palsy; dx mri
Taper gradually to prevent seizure relapse
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
High dose IV methyleprednisone;

7. How to stop antiepileptic 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
Taper gradually to prevent seizure relapse
Construction apraxia; lesion in non dominant parietal lobe (right)
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

8. Patient with carbamazepine; What should be advice?
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
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;
It patient has electrolyte imbalance and hypothermia

9. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

10. MG
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe
Deficit in cranial nerve 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

11. How to differentiate botulism from tick born paralysis - GBS and MG
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
High dose IV methyleprednisone;
Distal lower motor neuron disease
Botulism has descending paralysis in contrast othere have ascending paralysis

12. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

13. craniopharyngioma
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Diabetes insipidus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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;

14. Unable to copy of matchstick - unable to dress up
Clonidine will take care both high bp and withdrawal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)
High dose IV methyleprednisone;

15. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Corticosteroid and acyclovir
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

16. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Get up from chair walk a short distance turn around and sit; screening test for fall
Reduced efficacy of OCP
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.

17. best diagnosis for parkinsonim
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Autospy gold standard
MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

18. Should we tx htn in acute ischemic stroke

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19. anerior and anteriomedial thigh paresthesia - decreased DTR
90% of right handed and 60% of left handed persons; speech and language function
Vitamin B12 deficiency
Lesion in nondominant temporal lobe
Femoral n lesion

20. excessive elevation of legs during walking (toe touch floor earlier than heels)
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Distal lower motor neuron disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

21. prodrome of vasovagal syncope
Aspirin - control HTN and swallow eval before giving any oral meds
Tunnel vision - diaphoresis - nausea - pallor
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS

22. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

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

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24. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
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
Normal pressure hydrocephalus
Upright supine position

25. contraindication of sumatripta
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
Lesion in nondominant temporal lobe
Spastic paraparesis
Coronary artery disease

26. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Corticosteroid and acyclovir
Reduced efficacy of OCP
Spastic paraparesis
Clonidine will take care both high bp and withdrawal

27. double vision at the end of day and ptosis
Entacapone - COMT inhibitor
Myasthenia; due to autoantibodies against acetylecholine receptor;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
High dose IV methyleprednisone;

28. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
82% specific for dementia
IVIG and plasmapheresis
20%

29. dementia plus urinary incontinence
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Normal pressure hydrocephalus
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;

30. What mmse score suggest dementia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Taper gradually to prevent seizure relapse
<20; if patient scores >25 benign forgetfulness
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

31. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
<20; if patient scores >25 benign forgetfulness
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cerebral palsy; dx mri

32. korsafoff psychosis
82% specific for dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

33. impaired hepatic conjugation of billirubin
Difficulty in writing - calculating - distinguishing left and write
Gilberts disease
Normal pressure hydrocephalus
Deficit in cranial nerve function

34. What is pronator drift
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
Get up from chair walk a short distance turn around and sit; screening test for fall
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
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

35. What percent of dementia is reversible
Spastic paraparesis
20%
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: CSF increased IgG -IgM and IgA also increased. not specific to MS

36. severe headache and high BP
Coronary artery disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

37. How to prevent prevent frequency of MS exacerbation
Cerebellar lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Myasthenia; due to autoantibodies against acetylecholine receptor;

38. How to differentiate parkinson and benign essential tremor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Taper gradually to prevent seizure relapse

39. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spastic paraparesis

40. What is can be used cluster headache prevention
Verapamil
IVIG and plasmapheresis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

41. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Upright supine position
Acetylecholinersterase inhibitors
Gilberts disease

42. impaired vibration and increased DTR
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Distal lower motor neuron disease
Vitamin B12 deficiency

43. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Taper gradually to prevent seizure relapse
Deficit in cranial nerve function

44. When to use dopamine agonist pramipexol in parkinson
IVIG and plasmapheresis
82% specific for dementia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

45. brain stem lesion
Deficit in cranial nerve function
Despite the term neuroma they arise from schwann cells - schwanoma
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
EPV - campylobacter - HSV

46. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Acetylecholinersterase inhibitors
Upright supine position
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

47. When to start fibrinolytic therapy in stroke patient?
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
90% of right handed and 60% of left handed persons; speech and language function

48. differentiate wenicke and korsakoff
Coronary artery 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
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000

49. Tx of bells palsy
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
Upright supine position
Corticosteroid and acyclovir
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

50. MMSE score of less than 24
Aspirin - control HTN and swallow eval before giving any oral meds
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening