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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. Patient with carbamazepine; What should be advice?
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Nystagmus on far lateral gaze

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

3. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Myasthenia; due to autoantibodies against acetylecholine receptor;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Botulism has descending paralysis in contrast othere have ascending paralysis

4. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Follows viral illness; vertigo - tinnitus - nausea. self limiting
RBC count >6000
Upright supine position
Difficulty in writing - calculating - distinguishing left and write

5. 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
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
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

6. oligoclonal band in CSF
Construction apraxia; lesion in non dominant parietal lobe (right)
EPV - campylobacter - HSV
MS
Cerebral palsy; dx mri

7. differentiate picks and huntington
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
Despite the term neuroma they arise from schwann cells - schwanoma
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
Construction apraxia; lesion in non dominant parietal lobe (right)

8. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
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;
Autospy gold standard
Normal pressure hydrocephalus

9. When to use brain spect scintigraphy to confirm brain death
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
82% specific for dementia
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
It patient has electrolyte imbalance and hypothermia

10. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Obturator n lesion
MS
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

11. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

12. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Propranolol or primidone
Cerebellar lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

13. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
It patient has electrolyte imbalance and hypothermia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Femoral n lesion

14. How to confirm braindeath?
High dose IV methyleprednisone;
Cerebellar lesion
Aspirin - control HTN and swallow eval before giving any oral meds
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. How to differentiate traumatic LP and SAH
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
90% of right handed and 60% of left handed persons; speech and language function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

16. How to tx acute exacerbation of MS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;

17. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Gilberts disease
Normal pressure hydrocephalus
Acetylecholinersterase inhibitors

18. prodrome of vasovagal syncope
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Botulism has descending paralysis in contrast othere have ascending paralysis
Distal lower motor neuron disease
Tunnel vision - diaphoresis - nausea - pallor

19. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
It patient has electrolyte imbalance and hypothermia
Antitoxin
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

20. What percent of dementia is reversible
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
20%
High dose IV methyleprednisone;

21. botulism
Antitoxin
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

22. benign essential tremor
Difficulty in writing - calculating - distinguishing left and write
Deficit in cranial nerve function
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone

23. cluster headache
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Botulism has descending paralysis in contrast othere have ascending paralysis

24. lesion in dominant parietal lobe
MS
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
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease

25. How to perform apnea test
Vitamin B12 deficiency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Spastic paraparesis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

26. stroke with lower facial palsy - pronator drift despite on aspirin
Diabetes insipidus
Verapamil
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Despite the term neuroma they arise from schwann cells - schwanoma

27. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
20%
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Despite the term neuroma they arise from schwann cells - schwanoma

28. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Gilberts disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

29. labyrinthitis
Antitoxin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Myasthenia; due to autoantibodies against acetylecholine receptor;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

30. Tx of GBS
Distal lower motor neuron disease
Autospy gold standard
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

31. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
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
It patient has electrolyte imbalance and hypothermia

32. women with unilateral eye pain; neurlogic symptoms here there at different times
High dose IV methyleprednisone;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

33. Should we tx htn in acute ischemic stroke

34. lesion in dominant tempora lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

35. Acute onset of left arm weakness
Upright supine position
Reduced efficacy of OCP
Deficit in cranial nerve function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

36. cortical lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Lesion in nondominant temporal lobe
IVIG and plasmapheresis
Aphasia - neglect - agnosia - acalculia etc

37. When to suspect traumatic LP
RBC count >6000
MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Despite the term neuroma they arise from schwann cells - schwanoma

38. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
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
20%
Follows viral illness; vertigo - tinnitus - nausea. self limiting

39. 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
Femoral n lesion
Distal lower motor neuron disease
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

40. medial thigh sensory loss and weakness in addcution
Obturator n lesion
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
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.
Propranolol or primidone

41. dominant parietal lobe on the left side
Construction apraxia; lesion in non dominant parietal lobe (right)
90% of right handed and 60% of left handed persons; speech and language function
Femoral n lesion
Difficulty in writing - calculating - distinguishing left and write

42. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Autospy gold standard
Cerebral palsy; dx mri
Distal lower motor neuron disease

43. brain stem 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
Deficit in cranial nerve function
High dose IV methyleprednisone;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

44. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Difficulty in writing - calculating - distinguishing left and write
RBC count >6000

45. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Upright supine position
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
Clonidine will take care both high bp and withdrawal

46. How to prevent prevent frequency of MS exacerbation
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Vitamin B12 deficiency

47. impaired hepatic conjugation of billirubin
Clonidine will take care both high bp and withdrawal
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
Gilberts disease
Autospy gold standard

48. What mmse score suggest dementia
IVIG and plasmapheresis
<20; if patient scores >25 benign forgetfulness
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

49. acoustic neuroma
Botulism has descending paralysis in contrast othere have ascending paralysis
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;
Aphasia - neglect - agnosia - acalculia etc
Despite the term neuroma they arise from schwann cells - schwanoma

50. MG
Acetylecholinersterase inhibitors
Vitamin B12 deficiency
High dose IV methyleprednisone;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA