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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. dementia plus urinary incontinence
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus

2. phenytoin and OCP
Reduced efficacy of OCP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Clonidine will take care both high bp and withdrawal
Upright supine position

3. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
RBC count >6000
Antitoxin
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

4. Tx of bells palsy
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
RBC count >6000
Corticosteroid and acyclovir
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

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

6. craniopharyngioma
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
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
Diabetes insipidus
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

7. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
90% of right handed and 60% of left handed persons; speech and language function

8. impaired vibration and increased DTR
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Vitamin B12 deficiency
Acetylecholinersterase inhibitors
Normal pressure hydrocephalus

9. labyrinthitis
Coronary artery disease
Deficit in cranial nerve function
MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting

10. GBS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Distal lower motor neuron disease
IVIG and plasmapheresis

11. differentiate lewy body dementia and vascular dementia
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

12. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Wernicke's encephalopathy; due to thiamine definition; medical emergency

13. Blood transfusion in hypothermia
Cholinesterase inhibitor; and antiparkinsonism drugs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
90% of right handed and 60% of left handed persons; speech and language function
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

14. infections in GBS
Vitamin B12 deficiency
EPV - campylobacter - HSV
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

15. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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
90% of right handed and 60% of left handed persons; speech and language function

16. How to differentiate medial and lateral pontine syndrome
90% of right handed and 60% of left handed persons; speech and language function
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
Entacapone - COMT inhibitor
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

17. What percent of dementia is reversible
Femoral n lesion
20%
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in writing - calculating - distinguishing left and write

18. indication of plasmapheresis in GBS
20%
Not within 24 hours; give afte 24-48 hours if patient stable
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

19. 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;
MS
Upright supine position
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

20. excessive elevation of legs during walking (toe touch floor earlier than heels)
EPV - campylobacter - HSV
Vitamin B12 deficiency
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

21. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard
Diabetes insipidus

22. Unable to copy of matchstick - unable to dress up
Aphasia - neglect - agnosia - acalculia etc
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Construction apraxia; lesion in non dominant parietal lobe (right)
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

23. 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
Tunnel vision - diaphoresis - nausea - pallor
EPV - campylobacter - HSV
Difficulty in writing - calculating - distinguishing left and write

24. lesion in dominant tempora lobe
Aphasia - neglect - agnosia - acalculia etc
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

25. cluster headache
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Coronary artery disease
Clonidine will take care both high bp and withdrawal
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

26. prodrome of vasovagal syncope
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
20%
Tunnel vision - diaphoresis - nausea - pallor

27. best diagnosis for parkinsonim
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Autospy gold standard
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Tunnel vision - diaphoresis - nausea - pallor

28. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Construction apraxia; lesion in non dominant parietal lobe (right)

29. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Construction apraxia; lesion in non dominant parietal lobe (right)
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Gilberts disease

30. double vision at the end of day and ptosis
20%
Reduced efficacy of OCP
90% of right handed and 60% of left handed persons; speech and language function
Myasthenia; due to autoantibodies against acetylecholine receptor;

31. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Normal pressure hydrocephalus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Acetylecholinersterase inhibitors

32. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tunnel vision - diaphoresis - nausea - pallor
Not within 24 hours; give afte 24-48 hours if patient stable

33. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Obturator n lesion
Cerebral palsy; dx mri
RBC count >6000
Clonidine will take care both high bp and withdrawal

34. Should we tx htn in acute ischemic stroke

35. MG
Acetylecholinersterase inhibitors
Corticosteroid and acyclovir
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

36. How to tx lewy body dementia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Cholinesterase inhibitor; and antiparkinsonism drugs
Obturator n lesion
Spastic paraparesis

37. How to differentiate traumatic LP and SAH
Construction apraxia; lesion in non dominant parietal lobe (right)
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

38. Patient with carbamazepine; What should be advice?
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
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. MMSE score of less than 24
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.
Gilberts disease
Cerebral palsy; dx mri
82% specific for dementia

40. contraindication of sumatripta
Coronary artery disease
Entacapone - COMT inhibitor
MS
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

41. impaired perception of complex sounds
Autospy gold standard
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Lesion in nondominant temporal lobe
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

42. differentiate picks and huntington
RBC count >6000
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
Despite the term neuroma they arise from schwann cells - schwanoma
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

43. When headache is presenting complaint of brain tumor
Spastic paraparesis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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;

44. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
IVIG and plasmapheresis
Upright supine position
Entacapone - COMT inhibitor

45. When to use brain spect scintigraphy to confirm brain death
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
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
It patient has electrolyte imbalance and hypothermia
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

46. dominant parietal lobe on the left side
MS
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
90% of right handed and 60% of left handed persons; speech and language function

47. When to suspect traumatic LP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
RBC count >6000

48. get up and go test
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease
Get up from chair walk a short distance turn around and sit; screening test for fall

49. How to tx acute exacerbation of MS
Myasthenia; due to autoantibodies against acetylecholine receptor;
High dose IV methyleprednisone;
Antitoxin
Clonidine will take care both high bp and withdrawal

50. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Get up from chair walk a short distance turn around and sit; screening test for fall
Vitamin B12 deficiency
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA