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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. botulism
Reduced efficacy of OCP
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Antitoxin

2. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Construction apraxia; lesion in non dominant parietal lobe (right)
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
82% specific for dementia

3. 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
Tunnel vision - diaphoresis - nausea - pallor
Diabetes insipidus
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

4. medial thigh sensory loss and weakness in addcution
Botulism has descending paralysis in contrast othere have ascending paralysis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Taper gradually to prevent seizure relapse
Obturator n lesion

5. What is can be used cluster headache prevention
Entacapone - COMT inhibitor
Reduced efficacy of OCP
Verapamil
Wernicke's encephalopathy; due to thiamine definition; medical emergency

6. When to use brain spect scintigraphy to confirm brain death
Despite the term neuroma they arise from schwann cells - schwanoma
MS
It patient has electrolyte imbalance and hypothermia
Tunnel vision - diaphoresis - nausea - pallor

7. How to differentiate medial and lateral pontine syndrome
90% of right handed and 60% of left handed persons; speech and language function
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

8. impaired hepatic conjugation of billirubin
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

9. differentiate wenicke and korsakoff
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
Difficulty in writing - calculating - distinguishing left and write
Coronary artery disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

10. stroke with lower facial palsy - pronator drift despite on aspirin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

11. How to stop antiepileptic drugs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Taper gradually to prevent seizure relapse
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)

12. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
IVIG and plasmapheresis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

13. contraindication of sumatripta
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Normal pressure hydrocephalus
Coronary artery disease
Taper gradually to prevent seizure relapse

14. How to manage stroke patient came within 4 hours
Construction apraxia; lesion in non dominant parietal lobe (right)
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
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;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

15. Should we tx htn in acute ischemic stroke

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16. brain stem lesion
Deficit in cranial nerve function
Vitamin B12 deficiency
Difficulty in writing - calculating - distinguishing left and write
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

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

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18. Tx of bells palsy
Corticosteroid and acyclovir
Botulism has descending paralysis in contrast othere have ascending paralysis
82% specific for dementia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

19. differentiate picks and huntington
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone
Antitoxin

20. infections in GBS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
EPV - campylobacter - HSV
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Normal pressure hydrocephalus

21. best diagnosis for parkinsonim
Autospy gold standard
It patient has electrolyte imbalance and hypothermia
Upright supine position
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

22. what drug is used to extend effects of levodopa
90% of right handed and 60% of left handed persons; speech and language function
Construction apraxia; lesion in non dominant parietal lobe (right)
Entacapone - COMT inhibitor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

23. anerior and anteriomedial thigh paresthesia - decreased DTR
Construction apraxia; lesion in non dominant parietal lobe (right)
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
<20; if patient scores >25 benign forgetfulness
Femoral n lesion

24. Blood transfusion in hypothermia
Normal pressure hydrocephalus
20%
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Obturator n lesion

25. earliest sign of phenytoin toxicity
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Deficit in cranial nerve function
Entacapone - COMT inhibitor
Nystagmus on far lateral gaze

26. labyrinthitis
Acetylecholinersterase inhibitors
Propranolol or primidone
Upright supine position
Follows viral illness; vertigo - tinnitus - nausea. self limiting

27. How to tx stroke patient came after 6h
Entacapone - COMT inhibitor
Normal pressure hydrocephalus
Get up from chair walk a short distance turn around and sit; screening test for fall
Aspirin - control HTN and swallow eval before giving any oral meds

28. What is pronator drift
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
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
RBC count >6000
Diabetes insipidus

29. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Cholinesterase inhibitor; and antiparkinsonism 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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

30. prodrome of vasovagal syncope
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Tunnel vision - diaphoresis - nausea - pallor

31. indication of plasmapheresis in GBS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Aphasia - neglect - agnosia - acalculia etc

32. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Distal lower motor neuron disease
Normal pressure hydrocephalus
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

33. Unable to copy of matchstick - unable to dress up
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Construction apraxia; lesion in non dominant parietal lobe (right)
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting

34. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
90% of right handed and 60% of left handed persons; speech and language function
High dose IV methyleprednisone;
Upright supine position

35. impaired vibration and increased DTR
Clonidine will take care both high bp and withdrawal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Vitamin B12 deficiency
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

36. at first tingling in toes and feet then weakness in extremities
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
Nystagmus on far lateral gaze
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

37. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Nystagmus on far lateral gaze

38. How to tx acute exacerbation of MS
82% specific for dementia
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal
High dose IV methyleprednisone;

39. dementia plus urinary incontinence
Normal pressure hydrocephalus
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable

40. Patient with carbamazepine; What should be advice?
82% specific for dementia
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
Femoral n lesion

41. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Clonidine will take care both high bp and withdrawal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Wernicke's encephalopathy; due to thiamine definition; medical emergency

42. phenytoin and OCP
Reduced efficacy of OCP
Aphasia - neglect - agnosia - acalculia etc
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.

43. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Diabetes insipidus
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

44. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Distal lower motor neuron disease
Normal pressure hydrocephalus
Verapamil

45. When to start fibrinolytic therapy in stroke patient?
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
Coronary artery disease
MS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

46. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

47. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Despite the term neuroma they arise from schwann cells - schwanoma
Verapamil
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

48. women with unilateral eye pain; neurlogic symptoms here there at different times
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Deficit in cranial nerve function
Reduced efficacy of OCP

49. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
20%
Construction apraxia; lesion in non dominant parietal lobe (right)
Nystagmus on far lateral gaze

50. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Autospy gold standard
MS