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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. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Nystagmus on far lateral gaze

2. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
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;
Distal lower motor neuron disease
Cholinesterase inhibitor; and antiparkinsonism drugs

3. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Get up from chair walk a short distance turn around and sit; screening test for fall
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Propranolol or primidone
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

4. excessive elevation of legs during walking (toe touch floor earlier than heels)
Botulism has descending paralysis in contrast othere have ascending paralysis
Distal lower motor neuron disease
Antitoxin
High dose IV methyleprednisone;

5. phenytoin and OCP
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.
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
Reduced efficacy of OCP
Autospy gold standard

6. How to differentiate medial and lateral pontine syndrome
Despite the term neuroma they arise from schwann cells - schwanoma
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
It patient has electrolyte imbalance and hypothermia
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. What is can be used cluster headache prevention
Aspirin - control HTN and swallow eval before giving any oral meds
Verapamil
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

8. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
<20; if patient scores >25 benign forgetfulness
Femoral n lesion
Difficulty in writing - calculating - distinguishing left and write

9. differentiate picks and huntington
Not within 24 hours; give afte 24-48 hours if patient stable
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
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
Diabetes insipidus

10. botulism
RBC count >6000
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Antitoxin
Coronary artery disease

11. medial thigh sensory loss and weakness in addcution
Nystagmus on far lateral gaze
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Obturator n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

12. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
20%
82% specific for dementia

13. craniopharyngioma
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Diabetes insipidus
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

14. 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
EPV - campylobacter - HSV
High dose IV methyleprednisone;
Aphasia - neglect - agnosia - acalculia etc

15. anerior and anteriomedial thigh paresthesia - decreased DTR
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
Femoral n lesion
Reduced efficacy of OCP
Construction apraxia; lesion in non dominant parietal lobe (right)

16. double vision at the end of day and ptosis
<20; if patient scores >25 benign forgetfulness
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

17. best diagnosis for parkinsonim
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Autospy gold standard
RBC count >6000

18. differentiate wenicke and korsakoff
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
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.
Deficit in cranial nerve function

19. When to use brain spect scintigraphy to confirm brain death
Upright supine position
Not within 24 hours; give afte 24-48 hours if patient stable
High dose IV methyleprednisone;
It patient has electrolyte imbalance and hypothermia

20. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Upright supine position
RBC count >6000
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

21. stroke with lower facial palsy - pronator drift despite on aspirin
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
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;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

22. brain stem lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Deficit in cranial nerve function
Corticosteroid and acyclovir
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

23. what drug is used to extend effects of 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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Entacapone - COMT inhibitor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

24. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
High dose IV methyleprednisone;
Cerebellar lesion

25. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Autospy gold standard
High dose IV methyleprednisone;

26. What mmse score suggest dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
<20; if patient scores >25 benign forgetfulness
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
RBC count >6000

27. labyrinthitis
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe

28. How to confirm braindeath?
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
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
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.

29. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

30. 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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Difficulty in writing - calculating - distinguishing left and write
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

31. What percent of dementia is reversible
20%
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acetylecholinersterase inhibitors
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

32. What is pronator drift
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

33. acoustic neuroma
Propranolol or primidone
Taper gradually to prevent seizure relapse
Despite the term neuroma they arise from schwann cells - schwanoma
Gilberts disease

34. women with unilateral eye pain; neurlogic symptoms here there at different times
Deficit in cranial nerve function
Nystagmus on far lateral gaze
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Upright supine position

35. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Clonidine will take care both high bp and withdrawal
Normal pressure hydrocephalus
Antitoxin

36. MG
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
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
Aphasia - neglect - agnosia - acalculia etc
Acetylecholinersterase inhibitors

37. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
<20; if patient scores >25 benign forgetfulness
Cerebral palsy; dx mri
Diabetes insipidus

38. How to differentiate traumatic LP and SAH
82% specific for dementia
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
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;

39. impaired perception of complex sounds
Coronary artery disease
Tunnel vision - diaphoresis - nausea - pallor
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe

40. How to tx stroke patient came after 6h
Corticosteroid and acyclovir
Aspirin - control HTN and swallow eval before giving any oral meds
Botulism has descending paralysis in contrast othere have ascending paralysis
Entacapone - COMT inhibitor

41. 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
EPV - campylobacter - HSV
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

42. oligoclonal band in CSF
MS
Nystagmus on far lateral gaze
Verapamil
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

43. When to use dopamine agonist pramipexol in parkinson
Aphasia - neglect - agnosia - acalculia etc
Femoral n lesion
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

44. When headache is presenting complaint of brain tumor
Verapamil
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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.
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

45. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
Clonidine will take care both high bp and withdrawal
Myasthenia; due to autoantibodies against acetylecholine receptor;

46. cortical lesion
20%
Aphasia - neglect - agnosia - acalculia etc
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

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

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48. GBS
Cerebellar lesion
90% of right handed and 60% of left handed persons; speech and language function
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
IVIG and plasmapheresis

49. contraindication of sumatripta
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Coronary artery disease
Lesion in nondominant temporal lobe
Reduced efficacy of OCP

50. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aspirin - control HTN and swallow eval before giving any oral meds