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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. How to confirm braindeath?
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe
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.
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

2. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Femoral n lesion
Cerebral palsy; dx mri
Clonidine will take care both high bp and withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

3. How to tx stroke patient came after 6h
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aspirin - control HTN and swallow eval before giving any oral meds
Botulism has descending paralysis in contrast othere have ascending paralysis

4. oligoclonal band in CSF
MS
EPV - campylobacter - HSV
Aspirin - control HTN and swallow eval before giving any oral meds
Coronary artery disease

5. 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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aphasia - neglect - agnosia - acalculia etc
EPV - campylobacter - HSV

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

7. labyrinthitis
Deficit in cranial nerve function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

8. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP
Corticosteroid and acyclovir
Normal pressure hydrocephalus

9. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Nystagmus on far lateral gaze
RBC count >6000
Myasthenia; due to autoantibodies against acetylecholine receptor;

10. What is pronator drift
<20; if patient scores >25 benign forgetfulness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Entacapone - COMT inhibitor

11. botulism
Antitoxin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

12. How to tx acute exacerbation of MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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.
High dose IV methyleprednisone;
Gilberts disease

13. Blood transfusion in hypothermia
High dose IV methyleprednisone;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Antitoxin

14. impaired hepatic conjugation of billirubin
Gilberts disease
Autospy gold standard
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

15. Patient with carbamazepine; What should be advice?
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Propranolol or primidone
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

16. lesion in dominant tempora lobe
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Normal pressure hydrocephalus
Lesion in nondominant temporal lobe

17. How to stop antiepileptic drugs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Taper gradually to prevent seizure relapse
Wernicke's encephalopathy; due to thiamine definition; medical emergency
IVIG and plasmapheresis

18. 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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
IVIG and plasmapheresis
Vitamin B12 deficiency

19. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

20. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

21. anerior and anteriomedial thigh paresthesia - decreased DTR
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease

22. benign essential tremor
Propranolol or primidone
Nystagmus on far lateral gaze
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
<20; if patient scores >25 benign forgetfulness

23. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Construction apraxia; lesion in non dominant parietal lobe (right)
Myasthenia; due to autoantibodies against acetylecholine receptor;
Antitoxin

24. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
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
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
RBC count >6000

25. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
90% of right handed and 60% of left handed persons; speech and language function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

26. dominant parietal lobe on the left side
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri
90% of right handed and 60% of left handed persons; speech and language function

27. How to differentiate traumatic LP and SAH
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

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
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
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
Distal lower motor neuron disease

29. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tunnel vision - diaphoresis - nausea - pallor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
82% specific for dementia

30. 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
Tunnel vision - diaphoresis - nausea - pallor
Obturator n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

31. Should we tx htn in acute ischemic stroke

32. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar 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
Diabetes insipidus
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

33. indication of plasmapheresis in GBS
Distal lower motor neuron disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

34. korsafoff psychosis
EPV - campylobacter - HSV
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

35. When to use dopamine agonist pramipexol in parkinson
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebellar lesion
Nystagmus on far lateral gaze

36. How to differentiate medial and lateral pontine syndrome
Femoral n lesion
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
Reduced efficacy of OCP
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

37. impaired perception of complex sounds
Despite the term neuroma they arise from schwann cells - schwanoma
Lesion in nondominant temporal lobe
Tunnel vision - diaphoresis - nausea - pallor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

38. contraindication of sumatripta
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Coronary artery disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Deficit in cranial nerve function

39. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Acetylecholinersterase inhibitors
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

40. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Upright supine position
Aspirin - control HTN and swallow eval before giving any oral meds
Clonidine will take care both high bp and withdrawal

41. MG
Acetylecholinersterase inhibitors
Get up from chair walk a short distance turn around and sit; screening test for fall
Propranolol or primidone
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

42. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Reduced efficacy of OCP
Taper gradually to prevent seizure relapse
Nystagmus on far lateral gaze

43. How to tx lewy body dementia
Construction apraxia; lesion in non dominant parietal lobe (right)
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Cholinesterase inhibitor; and antiparkinsonism drugs

44. cluster headache
Verapamil
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Upright supine position
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

45. How to differentiate botulism from tick born paralysis - GBS and MG
Coronary artery disease
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Botulism has descending paralysis in contrast othere have ascending paralysis
RBC count >6000

46. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Tunnel vision - diaphoresis - nausea - pallor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

47. differentiate lewy body dementia and vascular dementia
Femoral n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Taper gradually to prevent seizure relapse

48. What percent of dementia is reversible
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
Diabetes insipidus
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
20%

49. MMSE score of less than 24
82% specific for dementia
Spastic paraparesis
Upright supine position
90% of right handed and 60% of left handed persons; speech and language function

50. What is can be used cluster headache prevention
Verapamil
It patient has electrolyte imbalance and hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Distal lower motor neuron disease