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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
Diabetes insipidus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

2. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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
<20; if patient scores >25 benign forgetfulness
Botulism has descending paralysis in contrast othere have ascending paralysis

3. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
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
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

4. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Aphasia - neglect - agnosia - acalculia etc
Lesion in nondominant temporal lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

5. How to confirm braindeath?
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
Spastic paraparesis
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.
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

6. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

7. Blood transfusion in hypothermia
Construction apraxia; lesion in non dominant parietal lobe (right)
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

8. at first tingling in toes and feet then weakness in extremities
Lesion in nondominant temporal lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;
Upright supine position
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

9. phenytoin and OCP
Corticosteroid and acyclovir
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Acetylecholinersterase inhibitors
Reduced efficacy of OCP

10. differentiate picks and huntington
Nystagmus on far lateral gaze
High dose IV methyleprednisone;
Cerebral palsy; dx mri
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

11. How to tx acute exacerbation of MS
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.
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
High dose IV methyleprednisone;
Get up from chair walk a short distance turn around and sit; screening test for fall

12. MMSE score of less than 24
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cholinesterase inhibitor; and antiparkinsonism drugs
82% specific for dementia
Get up from chair walk a short distance turn around and sit; screening test for fall

13. Unable to copy of matchstick - unable to dress up
Nystagmus on far lateral gaze
Not within 24 hours; give afte 24-48 hours if patient stable
Construction apraxia; lesion in non dominant parietal lobe (right)
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

14. Tx of bells palsy
Upright supine position
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease
Corticosteroid and acyclovir

15. anerior and anteriomedial thigh paresthesia - decreased DTR
IVIG and plasmapheresis
Distal lower motor neuron disease
Femoral n lesion
Coronary artery disease

16. earliest sign of phenytoin toxicity
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
Coronary artery disease
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

17. get up and go test
90% of right handed and 60% of left handed persons; speech and language function
Get up from chair walk a short distance turn around and sit; screening test for fall
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe

18. What percent of dementia is reversible
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
20%
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
Cerebellar lesion

19. infections in GBS
Gilberts disease
Construction apraxia; lesion in non dominant parietal lobe (right)
EPV - campylobacter - HSV
Vitamin B12 deficiency

20. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Antitoxin
<20; if patient scores >25 benign forgetfulness
Femoral n lesion

21. botulism
Antitoxin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MS
Tunnel vision - diaphoresis - nausea - pallor

22. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Vitamin B12 deficiency
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
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

23. How to differentiate parkinson and benign essential tremor
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
Gilberts disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

24. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Distal lower motor neuron disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

25. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Nystagmus on far lateral gaze
Distal lower motor neuron disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

26. lesion in dominant tempora lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

27. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tunnel vision - diaphoresis - nausea - pallor

28. women with unilateral eye pain; neurlogic symptoms here there at different times
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
EPV - campylobacter - HSV
Not within 24 hours; give afte 24-48 hours if patient stable

29. lesion in dominant parietal lobe
Lesion in nondominant temporal lobe
Difficulty in writing - calculating - distinguishing left and write
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

30. How to differentiate medial and lateral pontine syndrome
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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

31. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Spastic paraparesis
Upright supine position
Myasthenia; due to autoantibodies against acetylecholine receptor;

32. brain stem lesion
Deficit in cranial nerve function
Corticosteroid and acyclovir
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

33. cortical lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Upright supine position
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aphasia - neglect - agnosia - acalculia etc

34. differentiate wenicke and korsakoff
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

35. excessive elevation of legs during walking (toe touch floor earlier than heels)
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Distal lower motor neuron disease
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.
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

36. stroke with lower facial palsy - pronator drift despite on aspirin
Aphasia - neglect - agnosia - acalculia etc
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse
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

37. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Aphasia - neglect - agnosia - acalculia etc
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

38. 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
IVIG and plasmapheresis
Diabetes insipidus
Difficulty in writing - calculating - distinguishing left and write

39. Should we tx htn in acute ischemic stroke

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40. GBS
Taper gradually to prevent seizure relapse
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
IVIG and plasmapheresis

41. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Autospy gold standard
Taper gradually to prevent seizure relapse

42. What is pronator drift
Vitamin B12 deficiency
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
Taper gradually to prevent seizure relapse
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

43. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Antitoxin

44. What mmse score suggest dementia
Femoral n lesion
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds
EPV - campylobacter - HSV

45. 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
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
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

46. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Acetylecholinersterase inhibitors

47. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Antitoxin

48. When to use dopamine agonist pramipexol in parkinson
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

49. When to start fibrinolytic therapy in stroke patient?
Verapamil
Upright supine position
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

50. impaired perception of complex sounds
It patient has electrolyte imbalance and hypothermia
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Lesion in nondominant temporal lobe
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure