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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 diffrentiate tick borne paralysis from GBS and spinal cord tumor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)

2. best diagnosis for parkinsonim
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Autospy gold standard
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

3. How to differentiate parkinson and benign essential tremor
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
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
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

4. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Verapamil

5. korsafoff psychosis
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
MS
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Spastic paraparesis

6. prodrome of vasovagal syncope
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
Verapamil
Tunnel vision - diaphoresis - nausea - pallor
It patient has electrolyte imbalance and hypothermia

7. what drug is used to extend effects of levodopa
Difficulty in writing - calculating - distinguishing left and write
Entacapone - COMT inhibitor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

8. When to use dopamine agonist pramipexol in parkinson
Cerebral palsy; dx mri
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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;
Despite the term neuroma they arise from schwann cells - schwanoma

9. impaired hepatic conjugation of billirubin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Gilberts disease
Acetylecholinersterase inhibitors

10. What is can be used cluster headache prevention
Acetylecholinersterase inhibitors
Coronary artery disease
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

11. contraindication of sumatripta
Coronary artery disease
Despite the term neuroma they arise from schwann cells - schwanoma
High dose IV methyleprednisone;
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

12. medial thigh sensory loss and weakness in addcution
20%
Autospy gold standard
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Obturator n lesion

13. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus
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

14. get up and go test
Vitamin B12 deficiency
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Corticosteroid and acyclovir
Get up from chair walk a short distance turn around and sit; screening test for fall

15. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
EPV - campylobacter - HSV

16. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Distal lower motor neuron disease

17. What mmse score suggest dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Cerebellar lesion
<20; if patient scores >25 benign forgetfulness
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

18. Patient with carbamazepine; What should be advice?
Entacapone - COMT inhibitor
Construction apraxia; lesion in non dominant parietal lobe (right)
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

19. differentiate picks and huntington
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Entacapone - COMT inhibitor
EPV - campylobacter - HSV

20. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
EPV - campylobacter - HSV
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

21. indication of plasmapheresis in GBS
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
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;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs

22. Tx of GBS
Difficulty in writing - calculating - distinguishing left and write
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

23. dementia plus urinary incontinence
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
Normal pressure hydrocephalus
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;

24. How to stop antiepileptic drugs
Clonidine will take care both high bp and withdrawal
<20; if patient scores >25 benign forgetfulness
Taper gradually to prevent seizure relapse
Aspirin - control HTN and swallow eval before giving any oral meds

25. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Spastic paraparesis
Cholinesterase inhibitor; and antiparkinsonism drugs
Reduced efficacy of OCP

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

27. What bp med to be given in a patient with high bp and signs of opioid withdrawal
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Clonidine will take care both high bp and withdrawal
Vitamin B12 deficiency
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

28. women with unilateral eye pain; neurlogic symptoms here there at different times
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

29. brain stem lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Antitoxin
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor

30. at first tingling in toes and feet then weakness in extremities
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
IVIG and plasmapheresis

31. When to use brain spect scintigraphy to confirm brain death
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
High dose IV methyleprednisone;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
It patient has electrolyte imbalance and hypothermia

32. What percent of dementia is reversible
20%
Corticosteroid and acyclovir
Reduced efficacy of OCP
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

33. lesion in dominant parietal lobe
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
Difficulty in writing - calculating - distinguishing left and write
20%
Wernicke's encephalopathy; due to thiamine definition; medical emergency

34. Tx of bells palsy
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Corticosteroid and acyclovir
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

35. How to tx acute exacerbation of MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
High dose IV methyleprednisone;
20%
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

36. How to confirm braindeath?
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.
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
Normal pressure hydrocephalus

37. benign essential tremor
Propranolol or primidone
Verapamil
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Spastic paraparesis

38. How to tx stroke patient came after 6h
RBC count >6000
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
Autospy gold standard

39. What is pronator drift
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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;
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

40. Unable to copy of matchstick - unable to dress up
Verapamil
Normal pressure hydrocephalus
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Construction apraxia; lesion in non dominant parietal lobe (right)

41. How to manage stroke patient came within 4 hours
High dose IV methyleprednisone;
Spastic paraparesis
Upright supine position
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

42. labyrinthitis
Coronary artery disease
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Antitoxin
20%

43. How to differentiate dementias
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Cerebral palsy; dx mri

44. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Vitamin B12 deficiency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cholinesterase inhibitor; and antiparkinsonism drugs

45. How to perform apnea test
Clonidine will take care both high bp and withdrawal
High dose IV methyleprednisone;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

46. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Antitoxin
Upright supine position
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
82% specific for dementia

47. When headache is presenting complaint of brain tumor
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Reduced efficacy of OCP
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

48. botulism
Verapamil
Antitoxin
Cerebral palsy; dx mri
Acetylecholinersterase inhibitors

49. MMSE score of less than 24
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
82% specific for dementia
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

50. How to differentiate medial and lateral medullary syndrome
Lesion in nondominant temporal lobe
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;
Spontaneous remission; admit if suspected and monitor pulse ox for 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