Test your basic knowledge |

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. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
It patient has electrolyte imbalance and hypothermia
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
Diabetes insipidus
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

2. acoustic neuroma
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Nystagmus on far lateral gaze
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Despite the term neuroma they arise from schwann cells - schwanoma

3. severe headache and high BP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Antitoxin

4. How to tx stroke patient came after 6h
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

5. What is pronator drift
Lesion in nondominant temporal lobe
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
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
82% specific for dementia

6. Tx of bells palsy
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
Corticosteroid and acyclovir
IVIG and plasmapheresis

7. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aspirin - control HTN and swallow eval before giving any oral meds
EPV - campylobacter - HSV

8. How to differentiate medial and lateral medullary syndrome
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aphasia - neglect - agnosia - acalculia etc
Botulism has descending paralysis in contrast othere have ascending paralysis
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;

9. phenytoin and OCP
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Lesion in nondominant temporal lobe
Reduced efficacy of OCP
Myasthenia; due to autoantibodies against acetylecholine receptor;

10. prodrome of vasovagal syncope
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Tunnel vision - diaphoresis - nausea - pallor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Coronary artery disease

11. 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
Cerebellar lesion
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
Upright supine position

12. Should we tx htn in acute ischemic stroke

13. What percent of dementia is reversible
Get up from chair walk a short distance turn around and sit; screening test for fall
MS
20%
Autospy gold standard

14. at first tingling in toes and feet then weakness in extremities
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease

15. When headache is presenting complaint of brain tumor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Autospy gold standard
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

16. How to differentiate traumatic LP and SAH
Antitoxin
Despite the term neuroma they arise from schwann cells - schwanoma
<20; if patient scores >25 benign forgetfulness
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

17. contraindication of sumatripta
Coronary artery disease
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
IVIG and plasmapheresis

18. 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.
Deficit in cranial nerve function
Spastic paraparesis
Corticosteroid and acyclovir

19. indication of plasmapheresis in GBS
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
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma

20. How to differentiate parkinson and benign essential tremor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
IVIG and plasmapheresis

21. MG
Get up from chair walk a short distance turn around and sit; screening test for fall
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Construction apraxia; lesion in non dominant parietal lobe (right)
Acetylecholinersterase inhibitors

22. 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
Deficit in cranial nerve function
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

23. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
EPV - campylobacter - HSV
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

24. How to differentiate dementias
Cerebellar 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;
90% of right handed and 60% of left handed persons; speech and language function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

25. What is can be used cluster headache prevention
Verapamil
82% specific for dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

26. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Tunnel vision - diaphoresis - nausea - pallor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS

27. impaired hepatic conjugation of billirubin
Gilberts 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
MS
<20; if patient scores >25 benign forgetfulness

28. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
EPV - campylobacter - HSV
Autospy gold standard

29. When to use dopamine agonist pramipexol in parkinson
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
Propranolol or primidone
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
IVIG and plasmapheresis

30. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Distal lower motor neuron disease
Tunnel vision - diaphoresis - nausea - pallor
Verapamil
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

31. How to differentiate botulism from tick born paralysis - GBS and MG
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Normal pressure hydrocephalus
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

32. impaired perception of complex sounds
High dose IV methyleprednisone;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Lesion in nondominant temporal lobe
<20; if patient scores >25 benign forgetfulness

33. differentiate lewy body dementia and vascular dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

34. medial thigh sensory loss and weakness in addcution
90% of right handed and 60% of left handed persons; speech and language function
Obturator n lesion
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

35. When to suspect traumatic LP
RBC count >6000
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Femoral n lesion
Aspirin - control HTN and swallow eval before giving any oral meds

36. korsafoff psychosis
Not within 24 hours; give afte 24-48 hours if patient stable
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
Deficit in cranial nerve function
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

37. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Spastic paraparesis
Lesion in nondominant temporal lobe
It patient has electrolyte imbalance and hypothermia

38. infections in GBS
EPV - campylobacter - HSV
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Botulism has descending paralysis in contrast othere have ascending paralysis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

39. labyrinthitis
Despite the term neuroma they arise from schwann cells - schwanoma
Nystagmus on far lateral gaze
Botulism has descending paralysis in contrast othere have ascending paralysis
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Get up from chair walk a short distance turn around and sit; screening test for fall
Corticosteroid and acyclovir

41. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Gilberts disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

42. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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.
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebral palsy; dx mri

43. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Reduced efficacy of OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

44. Patient with carbamazepine; What should be advice?
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
RBC count >6000
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.
Cerebellar lesion

45. cortical lesion
Spastic paraparesis
IVIG and plasmapheresis
Aphasia - neglect - agnosia - acalculia etc
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

46. differentiate wenicke and 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
Aphasia - neglect - agnosia - acalculia etc
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
Propranolol or primidone

47. Tx of GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
It patient has electrolyte imbalance and hypothermia
Cerebral palsy; dx mri
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

48. lesion in dominant parietal lobe
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in writing - calculating - distinguishing left and write
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Diabetes insipidus

49. stroke with lower facial palsy - pronator drift despite on aspirin
20%
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
Not within 24 hours; give afte 24-48 hours if patient stable
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

50. women with unilateral eye pain; neurlogic symptoms here there at different times
Obturator n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aphasia - neglect - agnosia - acalculia etc
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty