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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. impaired vibration and increased DTR
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
Diabetes insipidus
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency

2. How to confirm braindeath?
Cerebral palsy; dx mri
Femoral n lesion
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.
Taper gradually to prevent seizure relapse

3. How to tx acute exacerbation of MS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

4. botulism
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
Antitoxin
Lesion in nondominant temporal lobe

5. oligoclonal band in CSF
Botulism has descending paralysis in contrast othere have ascending paralysis
MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
90% of right handed and 60% of left handed persons; speech and language function

6. When to start fibrinolytic therapy in stroke patient?
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Entacapone - COMT inhibitor

7. prodrome of vasovagal syncope
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Tunnel vision - diaphoresis - nausea - pallor
IVIG and plasmapheresis
Distal lower motor neuron disease

8. 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
Reduced efficacy of OCP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Nystagmus on far lateral gaze

9. When to suspect traumatic LP
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
82% specific for dementia
RBC count >6000
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

10. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Femoral n lesion
Aspirin - control HTN and swallow eval before giving any oral meds
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

11. How to tx stroke patient came after 6h
Construction apraxia; lesion in non dominant parietal lobe (right)
Cholinesterase inhibitor; and antiparkinsonism drugs
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aspirin - control HTN and swallow eval before giving any oral meds

12. How to manage stroke patient came within 4 hours
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
Tunnel vision - diaphoresis - nausea - pallor
Clonidine will take care both high bp and withdrawal
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

13. impaired hepatic conjugation of billirubin
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
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
Nystagmus on far lateral gaze
Gilberts disease

14. When headache is presenting complaint of brain tumor
Clonidine will take care both high bp and withdrawal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
RBC count >6000
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

15. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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.
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
20%

16. medial thigh sensory loss and weakness in addcution
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Upright supine position
Not within 24 hours; give afte 24-48 hours if patient stable
Obturator n lesion

17. How to differentiate botulism from tick born paralysis - GBS and MG
Cerebral palsy; dx mri
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Botulism has descending paralysis in contrast othere have ascending paralysis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

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

19. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
IVIG and plasmapheresis
Difficulty in writing - calculating - distinguishing left and write

20. What mmse score suggest dementia
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
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;
Difficulty in writing - calculating - distinguishing left and write

21. Should we tx htn in acute ischemic stroke

22. indication of plasmapheresis in GBS
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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;
Normal pressure hydrocephalus

23. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis

24. How to perform apnea test
Gilberts disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Vitamin B12 deficiency
Femoral n lesion

25. GBS
IVIG and plasmapheresis
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;
Diabetes insipidus

26. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Acetylecholinersterase inhibitors
Clonidine will take care both high bp and withdrawal
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Entacapone - COMT inhibitor

27. differentiate wenicke and korsakoff
Despite the term neuroma they arise from schwann cells - schwanoma
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable
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

28. When to use brain spect scintigraphy to confirm brain death
Femoral n lesion
Cerebellar lesion
It patient has electrolyte imbalance and hypothermia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

29. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
RBC count >6000

30. differentiate picks and huntington
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Antitoxin
Vitamin B12 deficiency
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

31. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
82% specific for dementia
Aphasia - neglect - agnosia - acalculia etc
Cerebral palsy; dx mri
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

32. earliest sign of phenytoin toxicity
Cholinesterase inhibitor; and antiparkinsonism drugs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Spastic paraparesis
Nystagmus on far lateral gaze

33. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

34. 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
Antitoxin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Not within 24 hours; give afte 24-48 hours if patient stable

35. lesion in dominant parietal lobe
Clonidine will take care both high bp and withdrawal
Cerebral palsy; dx mri
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in writing - calculating - distinguishing left and write

36. How to differentiate parkinson and benign essential tremor
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in writing - calculating - distinguishing left and write
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

37. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Upright supine position
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
EPV - campylobacter - HSV

38. MG
Acetylecholinersterase inhibitors
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Entacapone - COMT inhibitor

39. anerior and anteriomedial thigh paresthesia - decreased DTR
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
RBC count >6000
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Femoral n lesion

40. Patient with carbamazepine; What should be advice?
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Not within 24 hours; give afte 24-48 hours if patient stable

41. 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
Botulism has descending paralysis in contrast othere have ascending paralysis
90% of right handed and 60% of left handed persons; speech and language function
Obturator n lesion

42. When to use dopamine agonist pramipexol in parkinson
Diabetes insipidus
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
20%
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

43. Tx of GBS
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Obturator n lesion
Nystagmus on far lateral gaze

44. How to prevent prevent frequency of MS exacerbation
Vitamin B12 deficiency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Taper gradually to prevent seizure relapse
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

45. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Despite the term neuroma they arise from schwann cells - schwanoma

46. 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
20%
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
Propranolol or primidone

47. How to stop antiepileptic drugs
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
Taper gradually to prevent seizure relapse
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

48. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Aphasia - neglect - agnosia - acalculia etc
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
20%

49. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for 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.
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

50. contraindication of sumatripta
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Coronary artery disease
Gilberts disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner