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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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Entacapone - COMT inhibitor
Normal pressure hydrocephalus

2. How to tx acute exacerbation of MS
20%
High dose IV methyleprednisone;
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

3. 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
Coronary artery disease
Not within 24 hours; give afte 24-48 hours if patient stable
Obturator n lesion

4. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS

5. MG
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acetylecholinersterase inhibitors
Aphasia - neglect - agnosia - acalculia etc
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

6. at first tingling in toes and feet then weakness in extremities
Femoral n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

7. What is pronator drift
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
Diabetes insipidus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

8. benign essential tremor
It patient has electrolyte imbalance and hypothermia
Femoral n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Propranolol or primidone

9. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

10. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Gilberts disease
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spastic paraparesis

11. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
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
Coronary artery disease
EPV - campylobacter - HSV

12. Patient with carbamazepine; What should be advice?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

13. differentiate picks and huntington
82% specific for dementia
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Tunnel vision - diaphoresis - nausea - pallor

14. impaired hepatic conjugation of billirubin
Gilberts disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Myasthenia; due to autoantibodies against acetylecholine receptor;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

15. 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
Autospy gold standard
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
Lesion in nondominant temporal lobe

16. How to manage stroke patient came within 4 hours
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
IVIG and plasmapheresis

17. differentiate lewy body dementia and vascular dementia
High dose IV methyleprednisone;
IVIG and plasmapheresis
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

18. MMSE score of less than 24
20%
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency
82% specific for dementia

19. What percent of dementia is reversible
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
20%
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
Aspirin - control HTN and swallow eval before giving any oral meds

20. earliest sign of phenytoin toxicity
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
90% of right handed and 60% of left handed persons; speech and language function
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;
Nystagmus on far lateral gaze

21. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
High dose IV methyleprednisone;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Distal lower motor neuron disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

22. stroke with lower facial palsy - pronator drift despite on aspirin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Difficulty in writing - calculating - distinguishing left and write
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

23. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Verapamil
Upright supine position
Coronary artery disease

24. How to differentiate botulism from tick born paralysis - GBS and MG
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis
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

25. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Cerebral palsy; dx mri
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor

26. infections in GBS
EPV - campylobacter - HSV
Upright supine position
Not within 24 hours; give afte 24-48 hours if patient stable
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

27. How to differentiate traumatic LP and SAH
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
90% of right handed and 60% of left handed persons; speech and language function
Femoral n lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

28. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
<20; if patient scores >25 benign forgetfulness
Follows viral illness; vertigo - tinnitus - nausea. self limiting

29. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Taper gradually to prevent seizure relapse
Tunnel vision - diaphoresis - nausea - pallor
Coronary artery disease
Cerebral palsy; dx mri

30. When to start fibrinolytic therapy in stroke patient?
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

31. acoustic neuroma
Botulism has descending paralysis in contrast othere have ascending paralysis
Despite the term neuroma they arise from schwann cells - schwanoma
<20; if patient scores >25 benign forgetfulness
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

32. GBS
IVIG and plasmapheresis
High dose IV methyleprednisone;
Acetylecholinersterase inhibitors
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

33. What bp med to be given in a patient with high bp and signs of opioid withdrawal
MS
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
Clonidine will take care both high bp and withdrawal

34. Tx of GBS
Difficulty in writing - calculating - distinguishing left and write
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebellar lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

35. How to confirm braindeath?
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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.
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

36. How to prevent prevent frequency of MS exacerbation
Despite the term neuroma they arise from schwann cells - schwanoma
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

37. anerior and anteriomedial thigh paresthesia - decreased DTR
Botulism has descending paralysis in contrast othere have ascending paralysis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Femoral n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

38. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Construction apraxia; lesion in non dominant parietal lobe (right)
Clonidine will take care both high bp and withdrawal
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

39. differentiate wenicke and korsakoff
Spastic paraparesis
82% specific for dementia
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
Taper gradually to prevent seizure relapse

40. How to differentiate medial and lateral medullary syndrome
High dose IV methyleprednisone;
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

41. When to give aspirin when patient on tPA after stroke
Taper gradually to prevent seizure relapse
Normal pressure hydrocephalus
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
Not within 24 hours; give afte 24-48 hours if patient stable

42. Should we tx htn in acute ischemic stroke

43. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

44. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Deficit in cranial nerve function
Autospy gold standard
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

45. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Lesion in nondominant temporal lobe
90% of right handed and 60% of left handed persons; speech and language function
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

46. excessive elevation of legs during walking (toe touch floor earlier than heels)
Taper gradually to prevent seizure relapse
Clonidine will take care both high bp and withdrawal
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Distal lower motor neuron disease

47. dominant parietal lobe on the left side
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
RBC count >6000
90% of right handed and 60% of left handed persons; speech and language function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

48. get up and go test
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Deficit in cranial nerve function

49. craniopharyngioma
Normal pressure hydrocephalus
Diabetes insipidus
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.
Aspirin - control HTN and swallow eval before giving any oral meds

50. what drug is used to extend effects of levodopa
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
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
Aspirin - control HTN and swallow eval before giving any oral meds