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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 differentiate medial and lateral medullary syndrome
Aspirin - control HTN and swallow eval before giving any oral meds
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;
82% specific for dementia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

2. What is can be used cluster headache prevention
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cerebral palsy; dx mri

3. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Aphasia - neglect - agnosia - acalculia etc
Cholinesterase inhibitor; and antiparkinsonism drugs
Corticosteroid and acyclovir
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

4. medial thigh sensory loss and weakness in addcution
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
EPV - campylobacter - HSV
Reduced efficacy of OCP
Obturator n lesion

5. what drug is used to extend effects of levodopa
It patient has electrolyte imbalance and hypothermia
Entacapone - COMT inhibitor
Obturator n lesion
20%

6. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Taper gradually to prevent seizure relapse
Femoral n lesion
Deficit in cranial nerve function

7. cluster headache
Nystagmus on far lateral gaze
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
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

8. prodrome of vasovagal syncope
Acetylecholinersterase inhibitors
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
Tunnel vision - diaphoresis - nausea - pallor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

9. dementia plus urinary incontinence
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Propranolol or primidone
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Normal pressure hydrocephalus

10. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
IVIG and plasmapheresis
Aphasia - neglect - agnosia - acalculia etc
Upright supine position

11. How to differentiate traumatic LP and SAH
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

12. stroke with lower facial palsy - pronator drift despite on aspirin
Vitamin B12 deficiency
Coronary artery disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion

13. When to suspect traumatic LP
RBC count >6000
Autospy gold standard
90% of right handed and 60% of left handed persons; speech and language function
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

14. double vision at the end of day and ptosis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Myasthenia; due to autoantibodies against acetylecholine receptor;
High dose IV methyleprednisone;
RBC count >6000

15. best diagnosis for parkinsonim
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

16. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spastic paraparesis
Despite the term neuroma they arise from schwann cells - schwanoma

17. differentiate picks and huntington
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acetylecholinersterase inhibitors
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

18. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Get up from chair walk a short distance turn around and sit; screening test for fall
Lesion in nondominant temporal lobe

19. MMSE score of less than 24
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
82% specific for dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
90% of right handed and 60% of left handed persons; speech and language function

20. indication of plasmapheresis in GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Clonidine will take care both high bp and withdrawal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

21. Acute onset of left arm weakness
Entacapone - COMT inhibitor
Verapamil
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

22. phenytoin and OCP
Reduced efficacy of OCP
It patient has electrolyte imbalance and hypothermia
IVIG and plasmapheresis
Coronary artery disease

23. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
RBC count >6000
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
Cerebellar lesion

24. contraindication of sumatripta
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
Coronary artery disease
High dose IV methyleprednisone;

25. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
<20; if patient scores >25 benign forgetfulness
Spastic paraparesis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

26. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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;
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

27. Patient with carbamazepine; What should be advice?
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
Upright supine position
Botulism has descending paralysis in contrast othere have ascending paralysis
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

28. get up and go test
Not within 24 hours; give afte 24-48 hours if patient stable
Get up from chair walk a short distance turn around and sit; screening test for fall
82% specific for dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

29. 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
Obturator n lesion
Difficulty in writing - calculating - distinguishing left and write
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

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

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31. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Botulism has descending paralysis in contrast othere have ascending paralysis
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
82% specific for dementia

32. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Coronary artery disease
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
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

33. Should we tx htn in acute ischemic stroke

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34. How to differentiate parkinson and benign essential tremor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

35. GBS
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
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

36. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aphasia - neglect - agnosia - acalculia etc
Diabetes insipidus

37. What percent of dementia is reversible
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
20%
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

38. impaired perception of complex sounds
Vitamin B12 deficiency
Cerebellar lesion
Lesion in nondominant temporal lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

39. labyrinthitis
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
Femoral n lesion
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. Why V12 deficient develop hypokalemia after tx with b12
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;
Entacapone - COMT inhibitor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

41. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Antitoxin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
82% specific for dementia

42. 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
Cerebellar lesion
Get up from chair walk a short distance turn around and sit; screening test for fall
82% specific for dementia

43. When to start fibrinolytic therapy in stroke patient?
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
<20; if patient scores >25 benign forgetfulness
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

44. cortical lesion
20%
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Aphasia - neglect - agnosia - acalculia etc
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

45. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Get up from chair walk a short distance turn around and sit; screening test for fall
Aspirin - control HTN and swallow eval before giving any oral meds
Clonidine will take care both high bp and withdrawal
Tunnel vision - diaphoresis - nausea - pallor

46. How to manage stroke patient came within 4 hours
Acetylecholinersterase inhibitors
Vitamin B12 deficiency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

47. botulism
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
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;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Antitoxin

48. How to confirm braindeath?
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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.
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

49. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Aspirin - control HTN and swallow eval before giving any oral meds
Difficulty in writing - calculating - distinguishing left and write

50. How to prevent prevent frequency of MS exacerbation
Coronary artery disease
EPV - campylobacter - HSV
Difficulty in writing - calculating - distinguishing left and write
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised