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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. double vision at the end of day and ptosis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Gilberts disease
Myasthenia; due to autoantibodies against acetylecholine receptor;

2. anerior and anteriomedial thigh paresthesia - decreased DTR
Lesion in nondominant temporal lobe
Aphasia - neglect - agnosia - acalculia etc
20%
Femoral n lesion

3. When to use dopamine agonist pramipexol in parkinson
Construction apraxia; lesion in non dominant parietal lobe (right)
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aspirin - control HTN and swallow eval before giving any oral meds
Obturator n lesion

4. Tx of bells palsy
Corticosteroid and acyclovir
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
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

5. stroke with lower facial palsy - pronator drift despite on aspirin
Propranolol or primidone
Clonidine will take care both high bp and withdrawal
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

6. medial thigh sensory loss and weakness in addcution
Obturator n lesion
MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

7. How to tx stroke patient came after 6h
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Femoral n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds

8. craniopharyngioma
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
20%
Diabetes insipidus
Difficulty in writing - calculating - distinguishing left and write

9. How to differentiate dementias
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP

10. What mmse score suggest dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Reduced efficacy of OCP
<20; if patient scores >25 benign forgetfulness
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

11. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

12. women with unilateral eye pain; neurlogic symptoms here there at different times
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Verapamil
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

13. MG
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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
Acetylecholinersterase inhibitors
Autospy gold standard

14. Why V12 deficient develop hypokalemia after tx with b12
20%
Cerebellar lesion
Get up from chair walk a short distance turn around and sit; screening test for fall
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

15. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Botulism has descending paralysis in contrast othere have ascending paralysis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

16. How to confirm braindeath?
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.
IVIG and plasmapheresis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

17. phenytoin and OCP
Reduced efficacy of OCP
Distal lower motor neuron disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

18. differentiate picks and huntington
MS
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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

19. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

20. excessive elevation of legs during walking (toe touch floor earlier than heels)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Distal lower motor neuron disease
MS

21. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Spastic paraparesis
It patient has electrolyte imbalance and hypothermia
Entacapone - COMT inhibitor

22. contraindication of sumatripta
Coronary artery disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aphasia - neglect - agnosia - acalculia etc
Obturator n lesion

23. 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
Autospy gold standard
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
Aphasia - neglect - agnosia - acalculia etc

24. labyrinthitis
Propranolol or primidone
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Entacapone - COMT inhibitor

25. cortical lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aphasia - neglect - agnosia - acalculia etc
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

26. dominant parietal lobe on the left side
Autospy gold standard
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

27. When to give aspirin when patient on tPA after stroke
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Not within 24 hours; give afte 24-48 hours if patient stable
Obturator n lesion

28. How to differentiate parkinson and benign essential tremor
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
Distal lower motor neuron disease
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
Get up from chair walk a short distance turn around and sit; screening test for fall

29. How to differentiate medial and lateral medullary 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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Not within 24 hours; give afte 24-48 hours if patient stable
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 percent of dementia is reversible
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Vitamin B12 deficiency
20%

31. at first tingling in toes and feet then weakness in extremities
Not within 24 hours; give afte 24-48 hours if patient stable
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

32. lesion in dominant parietal lobe
Distal lower motor neuron disease
Difficulty in writing - calculating - distinguishing left and write
Reduced efficacy of OCP
Vitamin B12 deficiency

33. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
EPV - campylobacter - HSV
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

34. Unable to copy of matchstick - unable to dress up
Verapamil
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Construction apraxia; lesion in non dominant parietal lobe (right)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

35. How to differentiate traumatic LP and SAH
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cholinesterase inhibitor; and antiparkinsonism drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

36. cluster headache
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
Spastic paraparesis
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

37. infections in GBS
EPV - campylobacter - HSV
Spastic paraparesis
Difficulty in writing - calculating - distinguishing left and write
Upright supine position

38. When headache is presenting complaint of brain tumor
High dose IV methyleprednisone;
Aphasia - neglect - agnosia - acalculia etc
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

39. MMSE score of less than 24
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV
82% specific for dementia
Coronary artery disease

40. How to tx lewy body dementia
High dose IV methyleprednisone;
Vitamin B12 deficiency
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.
Cholinesterase inhibitor; and antiparkinsonism drugs

41. Tx of GBS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
<20; if patient scores >25 benign forgetfulness
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

42. get up and go test
Taper gradually to prevent seizure relapse
Get up from chair walk a short distance turn around and sit; screening test for fall
Autospy gold standard
Deficit in cranial nerve function

43. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Cerebellar lesion
Vitamin B12 deficiency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

44. indication of plasmapheresis in GBS
Corticosteroid and acyclovir
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

45. botulism
MS
Antitoxin
Entacapone - COMT inhibitor
Not within 24 hours; give afte 24-48 hours if patient stable

46. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
90% of right handed and 60% of left handed persons; speech and language function
IVIG and plasmapheresis

47. How to manage stroke patient came within 4 hours
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
20%

48. lesion in dominant tempora lobe
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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.
Antitoxin

49. When to suspect traumatic LP
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
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.
RBC count >6000
Coronary artery disease

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

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