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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. benign essential tremor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Botulism has descending paralysis in contrast othere have ascending paralysis
Propranolol or primidone
It patient has electrolyte imbalance and hypothermia

2. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Obturator n lesion
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

3. How to manage stroke patient came within 4 hours
Upright supine position
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

4. severe headache and high BP
Cholinesterase inhibitor; and antiparkinsonism drugs
Clonidine will take care both high bp and withdrawal
Taper gradually to prevent seizure relapse
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

5. Blood transfusion in hypothermia
Aphasia - neglect - agnosia - acalculia etc
Vitamin B12 deficiency
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

6. korsafoff psychosis
EPV - campylobacter - HSV
Gilberts 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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

7. How to differentiate medial and lateral medullary syndrome
Upright supine position
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;
Antitoxin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

8. MMSE score of less than 24
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
82% specific for dementia

9. impaired hepatic conjugation of billirubin
Corticosteroid and acyclovir
Gilberts disease
Taper gradually to prevent seizure relapse
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

10. When to use dopamine agonist pramipexol in parkinson
Myasthenia; due to autoantibodies against acetylecholine receptor;
RBC count >6000
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

11. phenytoin and OCP
Acetylecholinersterase inhibitors
Reduced efficacy of OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone

12. stroke with lower facial palsy - pronator drift despite on aspirin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acetylecholinersterase inhibitors
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

13. What percent of dementia is reversible
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;
Propranolol or primidone
20%
Botulism has descending paralysis in contrast othere have ascending paralysis

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

15. What is pronator drift
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs

16. contraindication of sumatripta
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Cerebellar lesion
<20; if patient scores >25 benign forgetfulness
Coronary artery disease

17. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Nystagmus on far lateral gaze
Antitoxin

18. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Difficulty in writing - calculating - distinguishing left and write
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
EPV - campylobacter - HSV
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

19. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Nystagmus on far lateral gaze
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Clonidine will take care both high bp and withdrawal

20. 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
Taper gradually to prevent seizure relapse
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write

21. What mmse score suggest dementia
Spastic paraparesis
Cerebral palsy; dx mri
<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

22. labyrinthitis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Myasthenia; due to autoantibodies against acetylecholine receptor;
Taper gradually to prevent seizure relapse
Follows viral illness; vertigo - tinnitus - nausea. self limiting

23. When headache is presenting complaint of brain tumor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Not within 24 hours; give afte 24-48 hours if patient stable
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

24. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

25. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

26. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
IVIG and plasmapheresis
Clonidine will take care both high bp and withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
RBC count >6000

27. dominant parietal lobe on the left side
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
90% of right handed and 60% of left handed persons; speech and language function

28. craniopharyngioma
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Verapamil
Diabetes insipidus
Distal lower motor neuron disease

29. cluster headache
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Obturator n lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

30. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Construction apraxia; lesion in non dominant parietal lobe (right)
Reduced efficacy of OCP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

31. best diagnosis for parkinsonim
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Obturator n lesion
Normal pressure hydrocephalus
Autospy gold standard

32. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in writing - calculating - distinguishing left and write
Follows viral illness; vertigo - tinnitus - nausea. self limiting
It patient has electrolyte imbalance and hypothermia

33. women with unilateral eye pain; neurlogic symptoms here there at different times
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
High dose IV methyleprednisone;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

34. impaired perception of complex sounds
Nystagmus on far lateral gaze
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Lesion in nondominant temporal lobe
Botulism has descending paralysis in contrast othere have ascending paralysis

35. cortical lesion
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
It patient has electrolyte imbalance and hypothermia
Aphasia - neglect - agnosia - acalculia etc
Spastic paraparesis

36. dementia plus urinary incontinence
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Normal pressure hydrocephalus

37. When to suspect traumatic LP
RBC count >6000
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Normal pressure hydrocephalus
Aspirin - control HTN and swallow eval before giving any oral meds

38. anerior and anteriomedial thigh paresthesia - decreased DTR
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Femoral n lesion
Normal pressure hydrocephalus
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

39. How to differentiate traumatic LP and SAH
Spastic paraparesis
Propranolol or primidone
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;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

40. Unable to copy of matchstick - unable to dress up
Deficit in cranial nerve function
Lesion in nondominant temporal lobe
Construction apraxia; lesion in non dominant parietal lobe (right)
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

41. Tx of bells palsy
<20; if patient scores >25 benign forgetfulness
Taper gradually to prevent seizure relapse
Corticosteroid and acyclovir
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

42. How to confirm braindeath?
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
Tunnel vision - diaphoresis - nausea - pallor
Cerebellar lesion
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. medial thigh sensory loss and weakness in addcution
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
Obturator n lesion
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;

44. infections in GBS
EPV - campylobacter - HSV
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Follows viral illness; vertigo - tinnitus - nausea. self limiting

45. prodrome of vasovagal syncope
Nystagmus on far lateral gaze
Tunnel vision - diaphoresis - nausea - pallor
Reduced efficacy of 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.

46. How to differentiate medial and lateral pontine syndrome
Aphasia - neglect - agnosia - acalculia etc
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
Lesion in nondominant temporal lobe
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

47. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Cerebral palsy; dx mri
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Reduced efficacy of OCP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

48. acoustic neuroma
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Despite the term neuroma they arise from schwann cells - schwanoma
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Clonidine will take care both high bp and withdrawal

49. How to tx stroke patient came after 6h
Cholinesterase inhibitor; and antiparkinsonism drugs
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Myasthenia; due to autoantibodies against acetylecholine receptor;
Aspirin - control HTN and swallow eval before giving any oral meds

50. indication of plasmapheresis in GBS
Normal pressure hydrocephalus
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
It patient has electrolyte imbalance and hypothermia