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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. acoustic neuroma
Cerebral palsy; dx mri
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

2. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Upright supine position

3. MG
Propranolol or primidone
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
Acetylecholinersterase inhibitors

4. How to differentiate botulism from tick born paralysis - GBS and MG
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Botulism has descending paralysis in contrast othere have ascending paralysis

5. Tx of bells palsy
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Cerebral palsy; dx mri
Corticosteroid and acyclovir
Upright supine position

6. How to tx acute exacerbation of MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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;
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

7. How to differentiate traumatic LP and SAH
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Upright supine position
Reduced efficacy of OCP

8. When to use brain spect scintigraphy to confirm brain death
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
It patient has electrolyte imbalance and hypothermia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Taper gradually to prevent seizure relapse

9. Unable to copy of matchstick - unable to dress up
Verapamil
Cerebellar lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Construction apraxia; lesion in non dominant parietal lobe (right)

10. stroke with lower facial palsy - pronator drift despite on aspirin
Lesion in nondominant temporal lobe
Femoral n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

11. GBS
IVIG and plasmapheresis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

12. How to differentiate medial and lateral medullary syndrome
Taper gradually to prevent seizure relapse
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;
Normal pressure hydrocephalus
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

13. oligoclonal band in CSF
MS
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;
<20; if patient scores >25 benign forgetfulness
It patient has electrolyte imbalance and hypothermia

14. prodrome of vasovagal syncope
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Tunnel vision - diaphoresis - nausea - pallor

15. dominant parietal lobe on the left side
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
90% of right handed and 60% of left handed persons; speech and language function
82% specific for dementia
Difficulty in writing - calculating - distinguishing left and write

16. cluster headache
Antitoxin
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

17. When to give aspirin when patient on tPA after stroke
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
Nystagmus on far lateral gaze
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable

18. double vision at the end of day and ptosis
82% specific for dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Myasthenia; due to autoantibodies against acetylecholine receptor;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

19. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Nystagmus on far lateral gaze
Clonidine will take care both high bp and withdrawal
Vitamin B12 deficiency
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.

20. MMSE score of less than 24
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
82% specific for dementia
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

21. impaired vibration and increased DTR
Vitamin B12 deficiency
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Clonidine will take care both high bp and withdrawal

22. 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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Corticosteroid and acyclovir
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

23. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Difficulty in writing - calculating - distinguishing left and write
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

24. How to manage stroke patient came within 4 hours
Not within 24 hours; give afte 24-48 hours if patient stable
Clonidine will take care both high bp and withdrawal
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Deficit in cranial nerve function

25. phenytoin and OCP
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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.
Botulism has descending paralysis in contrast othere have ascending paralysis

26. infections in GBS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebellar lesion
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
EPV - campylobacter - HSV

27. get up and go 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
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe
Get up from chair walk a short distance turn around and sit; screening test for fall

28. anerior and anteriomedial thigh paresthesia - decreased DTR
Taper gradually to prevent seizure relapse
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Femoral 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

29. differentiate lewy body dementia and vascular dementia
Cerebellar 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
Entacapone - COMT inhibitor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

30. impaired hepatic conjugation of billirubin
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts disease
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

31. best diagnosis for parkinsonim
Cholinesterase inhibitor; and antiparkinsonism drugs
Autospy gold standard
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aphasia - neglect - agnosia - acalculia etc

32. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

33. When to suspect traumatic LP
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;

34. what drug is used to extend effects of levodopa
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Vitamin B12 deficiency
Entacapone - COMT inhibitor
Acetylecholinersterase inhibitors

35. contraindication of sumatripta
Coronary artery 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
Normal pressure hydrocephalus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

36. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Upright supine position
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
EPV - campylobacter - HSV

37. botulism
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Difficulty in writing - calculating - distinguishing left and write
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

38. impaired perception of complex sounds
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Reduced efficacy of OCP
Cerebellar lesion
Lesion in nondominant temporal lobe

39. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cholinesterase inhibitor; and antiparkinsonism drugs
Despite the term neuroma they arise from schwann cells - schwanoma
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

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

41. How to differentiate parkinson and benign essential tremor
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;
Corticosteroid and acyclovir
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
Coronary artery disease

42. How to tx stroke patient came after 6h
Coronary artery disease
Aspirin - control HTN and swallow eval before giving any oral meds
Vitamin B12 deficiency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

43. 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

44. What percent of dementia is reversible
Verapamil
Nystagmus on far lateral gaze
Gilberts disease
20%

45. Blood transfusion in hypothermia
Gilberts disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

46. When headache is presenting complaint of brain tumor
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

47. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency

48. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Autospy gold standard
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

49. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Autospy gold standard
Myasthenia; due to autoantibodies against acetylecholine receptor;
Clonidine will take care both high bp and withdrawal

50. dementia plus urinary incontinence
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Normal pressure hydrocephalus
Diabetes insipidus
Femoral n lesion