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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. 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
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
82% specific for dementia

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

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3. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Get up from chair walk a short distance turn around and sit; screening test for fall
Obturator n lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

4. dominant parietal lobe on the left side
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Cerebral palsy; dx mri
90% of right handed and 60% of left handed persons; speech and language function

5. How to differentiate medial and lateral medullary syndrome
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;
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

6. When to suspect traumatic LP
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
RBC count >6000
Deficit in cranial nerve function
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

7. Should we tx htn in acute ischemic stroke

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8. How to perform apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Spastic paraparesis

9. Why V12 deficient develop hypokalemia after tx with b12
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Antitoxin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

10. labyrinthitis
Taper gradually to prevent seizure relapse
High dose IV methyleprednisone;
Cholinesterase inhibitor; and antiparkinsonism drugs
Follows viral illness; vertigo - tinnitus - nausea. self limiting

11. Unable to copy of matchstick - unable to dress up
90% of right handed and 60% of left handed persons; speech and language function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Construction apraxia; lesion in non dominant parietal lobe (right)

12. How to differentiate dementias
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable

13. impaired perception of complex sounds
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Clonidine will take care both high bp and withdrawal
Lesion in nondominant temporal lobe

14. what drug is used to extend effects of 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
Entacapone - COMT inhibitor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

15. cortical 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
Entacapone - COMT inhibitor
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc

16. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Cerebellar lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

17. MG
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.
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
High dose IV methyleprednisone;
Acetylecholinersterase inhibitors

18. When headache is presenting complaint of brain tumor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Autospy gold standard
Verapamil

19. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion
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;

20. phenytoin and OCP
Coronary artery disease
Tunnel vision - diaphoresis - nausea - pallor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Reduced efficacy of OCP

21. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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.
Wernicke's encephalopathy; due to thiamine definition; medical emergency

22. 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.
90% of right handed and 60% of left handed persons; speech and language function
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

23. brain stem lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Deficit in cranial nerve function
Propranolol or primidone
Wernicke's encephalopathy; due to thiamine definition; medical emergency

24. 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;
Cerebellar lesion
Autospy gold standard
Diabetes insipidus

25. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

26. When to give aspirin when patient on tPA after stroke
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Not within 24 hours; give afte 24-48 hours if patient stable
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

27. indication of plasmapheresis in GBS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
IVIG and plasmapheresis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

28. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of 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
Propranolol or primidone

29. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
<20; if patient scores >25 benign forgetfulness
Despite the term neuroma they arise from schwann cells - schwanoma
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

30. botulism
Botulism has descending paralysis in contrast othere have ascending paralysis
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

31. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Despite the term neuroma they arise from schwann cells - schwanoma
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

32. women with unilateral eye pain; neurlogic symptoms here there at different times
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
82% specific for dementia

33. korsafoff psychosis
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Botulism has descending paralysis in contrast othere have ascending paralysis

34. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
20%
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

35. craniopharyngioma
Diabetes insipidus
Vitamin B12 deficiency
Gilberts disease
Construction apraxia; lesion in non dominant parietal lobe (right)

36. 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
Not within 24 hours; give afte 24-48 hours if patient stable
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor

37. How to tx lewy body dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs

38. differentiate wenicke and korsakoff
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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

39. Tx of GBS
<20; if patient scores >25 benign forgetfulness
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
Deficit in cranial nerve function
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

40. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acetylecholinersterase inhibitors
Clonidine will take care both high bp and withdrawal
Aphasia - neglect - agnosia - acalculia etc

41. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Entacapone - COMT inhibitor
Obturator n lesion
IVIG and plasmapheresis

42. earliest sign of phenytoin toxicity
Cholinesterase inhibitor; and antiparkinsonism drugs
Nystagmus on far lateral gaze
Propranolol or primidone
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

43. Acute onset of left arm weakness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Normal pressure hydrocephalus
Aphasia - neglect - agnosia - acalculia etc

44. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Verapamil
Cholinesterase inhibitor; and antiparkinsonism drugs

45. medial thigh sensory loss and weakness in addcution
MS
Obturator n lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

46. How to differentiate parkinson and benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spontaneous remission; admit if suspected and monitor pulse ox for 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
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

47. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Get up from chair walk a short distance turn around and sit; screening test for fall
Cerebral palsy; dx mri
High dose IV methyleprednisone;

48. How to prevent prevent frequency of MS exacerbation
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV

49. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
20%
Cholinesterase inhibitor; and antiparkinsonism drugs
Difficulty in writing - calculating - distinguishing left and write

50. lesion in dominant parietal lobe
Deficit in cranial nerve function
MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Difficulty in writing - calculating - distinguishing left and write