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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. benign essential tremor
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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;
Propranolol or primidone

2. acoustic neuroma
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cholinesterase inhibitor; and antiparkinsonism drugs
Despite the term neuroma they arise from schwann cells - schwanoma
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

3. Tx of bells palsy
Taper gradually to prevent seizure relapse
Corticosteroid and acyclovir
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebral palsy; dx mri

4. Tx of GBS
Taper gradually to prevent seizure relapse
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Get up from chair walk a short distance turn around and sit; screening test for fall

5. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Aphasia - neglect - agnosia - acalculia etc
Upright supine position
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

6. craniopharyngioma
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spastic paraparesis
Diabetes insipidus

7. 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
Nystagmus on far lateral gaze
Wernicke's encephalopathy; due to thiamine definition; medical emergency
EPV - campylobacter - HSV

8. How to tx lewy body dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000
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

9. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Aspirin - control HTN and swallow eval before giving any oral meds
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
90% of right handed and 60% of left handed persons; speech and language function

10. Acute onset of left arm weakness
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

11. botulism
Spastic paraparesis
Antitoxin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
<20; if patient scores >25 benign forgetfulness

12. How to tx stroke patient came after 6h
Botulism has descending paralysis in contrast othere have ascending paralysis
Aspirin - control HTN and swallow eval before giving any oral meds
Cerebellar lesion
Clonidine will take care both high bp and withdrawal

13. impaired hepatic conjugation of billirubin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts disease

14. korsafoff psychosis
Cholinesterase inhibitor; and antiparkinsonism drugs
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

15. brain stem lesion
Deficit in cranial nerve function
Vitamin B12 deficiency
Upright supine position
Verapamil

16. dementia plus urinary incontinence
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Normal pressure hydrocephalus
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

17. When to suspect traumatic LP
RBC count >6000
Get up from chair walk a short distance turn around and sit; screening test for fall
Upright supine position
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

18. impaired vibration and increased DTR
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Vitamin B12 deficiency

19. oligoclonal band in CSF
MS
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Reduced efficacy of OCP
Clonidine will take care both high bp and withdrawal

20. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spastic paraparesis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

21. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Get up from chair walk a short distance turn around and sit; screening test for fall
Cerebral palsy; dx mri

22. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Gilberts disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position

23. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency

24. contraindication of sumatripta
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Coronary artery disease
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

25. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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;

26. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor

27. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MS
Nystagmus on far lateral gaze

28. women with unilateral eye pain; neurlogic symptoms here there at different times
Cerebellar lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Verapamil
<20; if patient scores >25 benign forgetfulness

29. How to manage stroke patient came within 4 hours
Cerebellar lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

30. differentiate picks and huntington
Coronary artery disease
Entacapone - COMT inhibitor
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
Corticosteroid and acyclovir

31. When to start fibrinolytic therapy in stroke patient?
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aphasia - neglect - agnosia - acalculia etc
Normal pressure hydrocephalus
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

32. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Cerebellar lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

33. lesion in dominant parietal lobe
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
Difficulty in writing - calculating - distinguishing left and write
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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

34. best diagnosis for parkinsonim
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

35. differentiate lewy body dementia and vascular dementia
RBC count >6000
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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; if patient scores >25 benign forgetfulness

36. at first tingling in toes and feet then weakness in extremities
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
IVIG and plasmapheresis
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

37. How to prevent prevent frequency of MS exacerbation
RBC count >6000
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
EPV - campylobacter - HSV

38. dominant parietal lobe on the left side
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
90% of right handed and 60% of left handed persons; speech and language function
82% specific for dementia

39. get up and go test
Coronary artery disease
Get up from chair walk a short distance turn around and sit; screening test for fall
20%
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

40. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Aspirin - control HTN and swallow eval before giving any oral meds
MS
Cerebral palsy; dx mri
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

41. Should we tx htn in acute ischemic stroke

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42. cluster headache
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
EPV - campylobacter - HSV
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

43. Blood transfusion in hypothermia
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
IVIG and plasmapheresis
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

44. MG
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Acetylecholinersterase inhibitors
Reduced efficacy of OCP
Gilberts disease

45. How to differentiate medial and lateral pontine syndrome
MS
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
Coronary artery disease

46. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Not within 24 hours; give afte 24-48 hours if patient stable
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Clonidine will take care both high bp and withdrawal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

47. How to differentiate parkinson and benign essential tremor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
82% specific for dementia
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
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

48. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Taper gradually to prevent seizure relapse
Propranolol or primidone
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

49. infections in GBS
EPV - campylobacter - HSV
Deficit in cranial nerve function
Normal pressure hydrocephalus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

50. what drug is used to extend effects of levodopa
Vitamin B12 deficiency
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Entacapone - COMT inhibitor