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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. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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.
Not within 24 hours; give afte 24-48 hours if patient stable
Difficulty in writing - calculating - distinguishing left and write
Spastic paraparesis

2. Tx of bells palsy
Gilberts disease
Corticosteroid and acyclovir
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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

3. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
<20; if patient scores >25 benign forgetfulness
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Tunnel vision - diaphoresis - nausea - pallor

4. How to differentiate medial and lateral pontine syndrome
Reduced efficacy of OCP
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
Not within 24 hours; give afte 24-48 hours if patient stable

5. cluster headache
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
IVIG and plasmapheresis

6. impaired vibration and increased DTR
Corticosteroid and acyclovir
Not within 24 hours; give afte 24-48 hours if patient stable
Vitamin B12 deficiency
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

7. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Upright supine position
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Acetylecholinersterase inhibitors

8. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MS
Entacapone - COMT inhibitor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

9. botulism
IVIG and plasmapheresis
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
Antitoxin

10. infections in GBS
EPV - campylobacter - HSV
Autospy gold standard
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

11. what drug is used to extend effects of levodopa
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
Entacapone - COMT inhibitor
Deficit in cranial nerve function
Wernicke's encephalopathy; due to thiamine definition; medical emergency

12. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Clonidine will take care both high bp and withdrawal
Reduced efficacy of OCP
Antitoxin

13. excessive elevation of legs during walking (toe touch floor earlier than heels)
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

14. differentiate lewy body dementia and vascular dementia
Aspirin - control HTN and swallow eval before giving any oral meds
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

15. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Despite the term neuroma they arise from schwann cells - schwanoma
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
20%

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;
Taper gradually to prevent seizure relapse
Normal pressure hydrocephalus
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

17. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Aphasia - neglect - agnosia - acalculia etc
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

18. 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;
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

19. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

20. What is pronator drift
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Cholinesterase inhibitor; and antiparkinsonism drugs
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
EPV - campylobacter - HSV

21. Unable to copy of matchstick - unable to dress up
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Construction apraxia; lesion in non dominant parietal lobe (right)
Botulism has descending paralysis in contrast othere have ascending paralysis

22. at first tingling in toes and feet then weakness in extremities
Clonidine will take care both high bp and withdrawal
Aspirin - control HTN and swallow eval before giving any oral meds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)

23. How to differentiate traumatic LP and SAH
Clonidine will take care both high bp and withdrawal
Upright supine position
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

24. How to confirm braindeath?
Tunnel vision - diaphoresis - nausea - pallor
20%
Cerebellar lesion
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.

25. 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
Diabetes insipidus
Reduced efficacy of OCP
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

26. When to use dopamine agonist pramipexol in parkinson
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Entacapone - COMT inhibitor

27. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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
Nystagmus on far lateral gaze
Normal pressure hydrocephalus

28. contraindication of sumatripta
Difficulty in writing - calculating - distinguishing left and write
Coronary artery 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
Clonidine will take care both high bp and withdrawal

29. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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;
Aspirin - control HTN and swallow eval before giving any oral meds
Tunnel vision - diaphoresis - nausea - pallor
Cerebral palsy; dx mri

30. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Femoral n lesion
Lesion in nondominant temporal lobe
82% specific for dementia

31. best diagnosis for parkinsonim
20%
Spastic paraparesis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Autospy gold standard

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

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33. What mmse score suggest dementia
Cerebellar lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
<20; if patient scores >25 benign forgetfulness

34. labyrinthitis
Aspirin - control HTN and swallow eval before giving any oral meds
Despite the term neuroma they arise from schwann cells - schwanoma
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

35. How to stop antiepileptic drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Wernicke's encephalopathy; due to thiamine definition; medical emergency
High dose IV methyleprednisone;
Taper gradually to prevent seizure relapse

36. indication of plasmapheresis in GBS
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)

37. korsafoff psychosis
Get up from chair walk a short distance turn around and sit; screening test for fall
It patient has electrolyte imbalance and hypothermia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

38. women with unilateral eye pain; neurlogic symptoms here there at different times
Verapamil
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Deficit in cranial nerve function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

39. cortical lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Gilberts disease
Aphasia - neglect - agnosia - acalculia etc
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

40. MG
Get up from chair walk a short distance turn around and sit; screening test for fall
Spastic paraparesis
Acetylecholinersterase inhibitors
Obturator n lesion

41. How to differentiate dementias
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Corticosteroid and acyclovir
Aspirin - control HTN and swallow eval before giving any oral meds

42. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Tunnel vision - diaphoresis - nausea - pallor
Corticosteroid and acyclovir
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Clonidine will take care both high bp and withdrawal

43. How to tx lewy body dementia
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
Corticosteroid and acyclovir
Cholinesterase inhibitor; and antiparkinsonism drugs
Autospy gold standard

44. phenytoin and OCP
20%
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Reduced efficacy of OCP
Spastic paraparesis

45. When to start fibrinolytic therapy in stroke patient?
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Distal lower motor neuron disease

46. dementia plus urinary incontinence
Upright supine position
Construction apraxia; lesion in non dominant parietal lobe (right)
Normal pressure hydrocephalus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

47. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
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
Clonidine will take care both high bp and withdrawal
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

48. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
82% specific for dementia
Aspirin - control HTN and swallow eval before giving any oral meds
Follows viral illness; vertigo - tinnitus - nausea. self limiting

49. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Get up from chair walk a short distance turn around and sit; screening test for fall
Verapamil

50. How to prevent prevent frequency of MS exacerbation
Gilberts disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l