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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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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. 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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
High dose IV methyleprednisone;
Diabetes insipidus

2. stroke with lower facial palsy - pronator drift despite on aspirin
It patient has electrolyte imbalance and hypothermia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

3. Acute onset of left arm weakness
Tunnel vision - diaphoresis - nausea - pallor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting

4. 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;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000

5. Why V12 deficient develop hypokalemia after tx with b12
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Get up from chair walk a short distance turn around and sit; screening test for fall
Obturator n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

6. How to differentiate botulism from tick born paralysis - GBS and MG
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
<20; if patient scores >25 benign forgetfulness
Botulism has descending paralysis in contrast othere have ascending paralysis

7. How to stop antiepileptic drugs
Obturator n lesion
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
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
Taper gradually to prevent seizure relapse

8. oligoclonal band in CSF
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS

9. differentiate picks and huntington
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Femoral n lesion
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
Propranolol or primidone

10. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

11. anerior and anteriomedial thigh paresthesia - decreased DTR
Nystagmus on far lateral gaze
Femoral n lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Normal pressure hydrocephalus

12. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

13. How to differentiate medial and lateral pontine 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
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Reduced efficacy of OCP

14. lesion in dominant tempora lobe
Taper gradually to prevent seizure relapse
Difficulty in writing - calculating - distinguishing left and write
Entacapone - COMT inhibitor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

15. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
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.
MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

16. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
20%
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;

17. What bp med to be given in a patient with high bp and signs of opioid withdrawal
MS
Clonidine will take care both high bp and withdrawal
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

18. get up and go test
Reduced efficacy of OCP
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
Get up from chair walk a short distance turn around and sit; screening test for fall
Lesion in nondominant temporal lobe

19. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Lesion in nondominant temporal lobe
Distal lower motor neuron disease

20. labyrinthitis
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;
Entacapone - COMT inhibitor
Autospy gold standard
Follows viral illness; vertigo - tinnitus - nausea. self limiting

21. Blood transfusion in hypothermia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Nystagmus on far lateral gaze

22. Tx of bells palsy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
EPV - campylobacter - HSV
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
Corticosteroid and acyclovir

23. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Spastic paraparesis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
EPV - campylobacter - HSV

24. 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
Not within 24 hours; give afte 24-48 hours if patient stable
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Construction apraxia; lesion in non dominant parietal lobe (right)

25. How to differentiate traumatic LP and SAH
Upright supine position
IVIG and plasmapheresis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Corticosteroid and acyclovir

26. 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
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Get up from chair walk a short distance turn around and sit; screening test for fall

27. medial thigh sensory loss and weakness in addcution
20%
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

28. earliest sign of phenytoin toxicity
Femoral n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Nystagmus on far lateral gaze
Cerebral palsy; dx mri

29. impaired perception of complex sounds
Lesion in nondominant temporal lobe
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
Femoral n lesion
Propranolol or primidone

30. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebral palsy; dx mri
Spastic paraparesis
20%

31. What percent of dementia is reversible
20%
Upright supine position
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

32. 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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Acetylecholinersterase inhibitors
EPV - campylobacter - HSV

33. prodrome of vasovagal syncope
Autospy gold standard
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

34. When to start fibrinolytic therapy in stroke patient?
Cerebral palsy; dx mri
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
High dose IV methyleprednisone;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

35. How to tx acute exacerbation of MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cholinesterase inhibitor; and antiparkinsonism drugs
High dose IV methyleprednisone;
Vitamin B12 deficiency

36. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Deficit in cranial nerve function
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
Despite the term neuroma they arise from schwann cells - schwanoma

37. impaired vibration and increased DTR
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Despite the term neuroma they arise from schwann cells - schwanoma

38. GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
IVIG and plasmapheresis
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
Cerebral palsy; dx mri

39. phenytoin and OCP
Not within 24 hours; give afte 24-48 hours if patient stable
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Reduced efficacy of OCP

40. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Aphasia - neglect - agnosia - acalculia etc
Upright supine position
Spastic paraparesis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

41. indication of plasmapheresis in GBS
Obturator n lesion
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

42. Should we tx htn in acute ischemic stroke

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43. korsafoff psychosis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV

44. MG
Acetylecholinersterase inhibitors
Wernicke's encephalopathy; due to thiamine definition; medical emergency
90% of right handed and 60% of left handed persons; speech and language function
Not within 24 hours; give afte 24-48 hours if patient stable

45. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
RBC count >6000
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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. What is pronator drift
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

47. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir
It patient has electrolyte imbalance and hypothermia

48. benign essential tremor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Propranolol or primidone
Corticosteroid and acyclovir
EPV - campylobacter - HSV

49. When to give aspirin when patient on tPA after stroke
Get up from chair walk a short distance turn around and sit; screening test for fall
Not within 24 hours; give afte 24-48 hours if patient stable
90% of right handed and 60% of left handed persons; speech and language function
Normal pressure hydrocephalus

50. impaired hepatic conjugation of billirubin
Gilberts disease
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
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

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USMLE Step3 Neurology

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