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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. stroke with lower facial palsy - pronator drift despite on aspirin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
IVIG and plasmapheresis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

2. How to tx acute exacerbation of MS
Obturator n lesion
High dose IV methyleprednisone;
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;

3. cortical lesion
Aspirin - control HTN and swallow eval before giving any oral meds
Cholinesterase inhibitor; and antiparkinsonism drugs
Aphasia - neglect - agnosia - acalculia etc
High dose IV methyleprednisone;

4. brain stem lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Botulism has descending paralysis in contrast othere have ascending paralysis
Deficit in cranial nerve function
Aspirin - control HTN and swallow eval before giving any oral meds

5. best diagnosis for parkinsonim
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
IVIG and plasmapheresis

6. Should we tx htn in acute ischemic stroke

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7. labyrinthitis
Nystagmus on far lateral gaze
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

8. phenytoin and OCP
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Reduced efficacy of OCP
82% specific for dementia

9. what drug is used to extend effects of levodopa
EPV - campylobacter - HSV
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Entacapone - COMT inhibitor
Antitoxin

10. When to use brain spect scintigraphy to confirm brain death
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Entacapone - COMT inhibitor
It patient has electrolyte imbalance and hypothermia

11. How to differentiate medial and lateral medullary syndrome
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;
<20; if patient scores >25 benign forgetfulness
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
20%

12. Patient with carbamazepine; What should be advice?
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
MS
Acetylecholinersterase inhibitors
Vitamin B12 deficiency

13. GBS
Distal lower motor neuron disease
Reduced efficacy of OCP
IVIG and plasmapheresis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

14. How to confirm braindeath?
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
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.
Tunnel vision - diaphoresis - nausea - pallor
Coronary artery disease

15. dementia plus urinary incontinence
Gilberts disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus

16. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Obturator n lesion
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

17. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebral palsy; dx mri
Propranolol or primidone
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
Cerebellar lesion

18. get up and go test
Coronary artery disease
EPV - campylobacter - HSV
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Get up from chair walk a short distance turn around and sit; screening test for fall

19. double vision at the end of day and ptosis
MS
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;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

20. 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
Difficulty in writing - calculating - distinguishing left and write
EPV - campylobacter - HSV
High dose IV methyleprednisone;

21. earliest sign of phenytoin toxicity
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Nystagmus on far lateral gaze
Aspirin - control HTN and swallow eval before giving any oral meds
Aphasia - neglect - agnosia - acalculia etc

22. lesion in dominant tempora lobe
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
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

23. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Deficit in cranial nerve function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

24. indication of plasmapheresis in GBS
Femoral n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Entacapone - COMT inhibitor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

25. MMSE score of less than 24
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
82% specific for 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

26. When to suspect traumatic LP
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
RBC count >6000
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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.

27. korsafoff psychosis
Coronary artery disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Reduced efficacy of OCP

28. medial thigh sensory loss and weakness in addcution
Aspirin - control HTN and swallow eval before giving any oral meds
Acetylecholinersterase inhibitors
Obturator n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

29. lesion in dominant parietal lobe
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease
Upright supine position

30. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

31. oligoclonal band in CSF
Myasthenia; due to autoantibodies against acetylecholine receptor;
Propranolol or primidone
MS
Normal pressure hydrocephalus

32. Blood transfusion in hypothermia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

33. excessive elevation of legs during walking (toe touch floor earlier than heels)
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Distal lower motor neuron disease

34. When to use dopamine agonist pramipexol in parkinson
Gilberts disease
RBC count >6000
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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

35. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Distal lower motor neuron disease
Propranolol or primidone
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

36. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Despite the term neuroma they arise from schwann cells - schwanoma
Corticosteroid and acyclovir
Entacapone - COMT inhibitor

37. Tx of GBS
Nystagmus on far lateral gaze
Corticosteroid and acyclovir
Difficulty in writing - calculating - distinguishing left and write
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

38. How to differentiate medial and lateral pontine syndrome
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

39. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
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

40. How to tx stroke patient came after 6h
Entacapone - COMT inhibitor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Aspirin - control HTN and swallow eval before giving any oral meds
Botulism has descending paralysis in contrast othere have ascending paralysis

41. How to prevent prevent frequency of MS exacerbation
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write
Despite the term neuroma they arise from schwann cells - schwanoma
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

42. prodrome of vasovagal syncope
82% specific for dementia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tunnel vision - diaphoresis - nausea - pallor
Antitoxin

43. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Cerebral palsy; dx mri
Wernicke's encephalopathy; due to thiamine definition; medical emergency
82% specific for dementia

44. craniopharyngioma
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Diabetes insipidus
Despite the term neuroma they arise from schwann cells - schwanoma

45. Unable to copy of matchstick - unable to dress up
MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Construction apraxia; lesion in non dominant parietal lobe (right)
EPV - campylobacter - HSV

46. When headache is presenting complaint of brain tumor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

47. 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

48. MG
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor
Acetylecholinersterase inhibitors

49. Acute onset of left arm weakness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Aspirin - control HTN and swallow eval before giving any oral meds
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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;

50. How to stop antiepileptic drugs
Follows viral illness; vertigo - tinnitus - nausea. self limiting
90% of right handed and 60% of left handed persons; speech and language function
Taper gradually to prevent seizure relapse
Aspirin - control HTN and swallow eval before giving any oral meds