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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. Should we tx htn in acute ischemic stroke

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2. 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
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

3. What percent of dementia is reversible
Get up from chair walk a short distance turn around and sit; screening test for fall
20%
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

4. What mmse score suggest dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Diabetes insipidus
<20; if patient scores >25 benign forgetfulness
Clonidine will take care both high bp and withdrawal

5. How to differentiate medial and lateral pontine syndrome
Corticosteroid and acyclovir
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
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.

6. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Clonidine will take care both high bp and withdrawal
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
Normal pressure hydrocephalus

7. labyrinthitis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
20%
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Verapamil

8. best diagnosis for parkinsonim
Autospy gold standard
Get up from chair walk a short distance turn around and sit; screening test for fall
<20; if patient scores >25 benign forgetfulness
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

9. Patient with carbamazepine; What should be advice?
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
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

10. Unable to copy of matchstick - unable to dress up
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Aphasia - neglect - agnosia - acalculia etc
Obturator n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)

11. phenytoin and OCP
Reduced efficacy of OCP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Upright supine position
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

12. What is can be used cluster headache prevention
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Verapamil
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
Clonidine will take care both high bp and withdrawal

13. cortical lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aphasia - neglect - agnosia - acalculia etc
Clonidine will take care both high bp and withdrawal
Lesion in nondominant temporal lobe

14. severe headache and high BP
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
82% specific for dementia
90% of right handed and 60% of left handed persons; speech and language function

15. what drug is used to extend effects of levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

16. 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;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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;
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

17. botulism
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
Antitoxin
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. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Reduced efficacy of OCP

19. Tx of GBS
Taper gradually to prevent seizure relapse
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

20. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000
Verapamil
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

21. 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

22. How to tx lewy body dementia
Antitoxin
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

23. differentiate picks and huntington
Upright supine position
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
Normal pressure hydrocephalus
Femoral n lesion

24. dementia plus urinary incontinence
RBC count >6000
Normal pressure hydrocephalus
Femoral n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

25. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Spastic paraparesis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

26. impaired vibration and increased DTR
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Vitamin B12 deficiency
Propranolol or primidone
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

27. What is pronator drift
90% of right handed and 60% of left handed persons; speech and language function
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
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
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

28. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cholinesterase inhibitor; and antiparkinsonism drugs

29. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
82% specific for dementia
<20; if patient scores >25 benign forgetfulness
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

30. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir
Obturator n lesion

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

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32. differentiate lewy body dementia and vascular dementia
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

33. anerior and anteriomedial thigh paresthesia - decreased DTR
Deficit in cranial nerve function
Construction apraxia; lesion in non dominant parietal lobe (right)
Femoral n lesion
Lesion in nondominant temporal lobe

34. infections in GBS
It patient has electrolyte imbalance and hypothermia
EPV - campylobacter - HSV
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Wernicke's encephalopathy; due to thiamine definition; medical emergency

35. differentiate wenicke and korsakoff
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

36. at first tingling in toes and feet then weakness in extremities
Aspirin - control HTN and swallow eval before giving any oral meds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

37. indication of plasmapheresis in GBS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
IVIG and plasmapheresis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

38. get up and go test
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis
90% of right handed and 60% of left handed persons; speech and language function
Get up from chair walk a short distance turn around and sit; screening test for fall

39. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Normal pressure hydrocephalus
Gilberts disease

40. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
RBC count >6000
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

41. craniopharyngioma
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus
Autospy gold standard

42. MG
Antitoxin
Botulism has descending paralysis in contrast othere have ascending paralysis
Acetylecholinersterase inhibitors
Diabetes insipidus

43. When headache is presenting complaint of brain tumor
Deficit in cranial nerve function
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

44. excessive elevation of legs during walking (toe touch floor earlier than heels)
Spastic paraparesis
Distal lower motor neuron disease
Taper gradually to prevent seizure relapse
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

45. earliest sign of phenytoin toxicity
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;
High dose IV methyleprednisone;
90% of right handed and 60% of left handed persons; speech and language function
Nystagmus on far lateral gaze

46. Why V12 deficient develop hypokalemia after tx with b12
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
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
Gilberts disease

47. lesion in dominant tempora lobe
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Distal lower motor neuron disease
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

48. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Tunnel vision - diaphoresis - nausea - pallor
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
Upright supine position

49. How to differentiate medial and lateral medullary syndrome
Not within 24 hours; give afte 24-48 hours if patient stable
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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;
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

50. benign essential tremor
Propranolol or primidone
Cerebral palsy; dx mri
Coronary artery disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure