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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. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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
Acetylecholinersterase inhibitors
Clonidine will take care both high bp and withdrawal
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

2. Tx of bells palsy
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
Corticosteroid and acyclovir
Deficit in cranial nerve function
Aspirin - control HTN and swallow eval before giving any oral meds

3. double vision at the end of day and ptosis
Upright supine position
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
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;

4. severe headache and high BP
Get up from chair walk a short distance turn around and sit; screening test for fall
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Verapamil
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.

5. differentiate picks and huntington
Reduced efficacy of OCP
MS
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

6. What is can be used cluster headache prevention
MS
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
Verapamil
<20; if patient scores >25 benign forgetfulness

7. benign essential tremor
It patient has electrolyte imbalance and hypothermia
Propranolol or primidone
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal

8. 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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

9. craniopharyngioma
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
Diabetes insipidus
Verapamil

10. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
82% specific for dementia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Femoral n lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

11. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Nystagmus on far lateral gaze

12. When to give aspirin when patient on tPA after stroke
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Entacapone - COMT inhibitor
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis

13. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
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
RBC count >6000

14. How to differentiate medial and lateral medullary syndrome
IVIG and plasmapheresis
Entacapone - COMT inhibitor
20%
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;

15. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Construction apraxia; lesion in non dominant parietal lobe (right)
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

16. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Nystagmus on far lateral gaze
Propranolol or primidone
Spastic paraparesis
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

17. acoustic neuroma
Aspirin - control HTN and swallow eval before giving any oral meds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Despite the term neuroma they arise from schwann cells - schwanoma

18. brain stem lesion
Deficit in cranial nerve function
Normal pressure hydrocephalus
Not within 24 hours; give afte 24-48 hours if patient stable
Coronary artery disease

19. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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;
Verapamil

20. Acute onset of left arm weakness
<20; if patient scores >25 benign forgetfulness
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

21. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Upright supine position

22. lesion in dominant tempora lobe
Construction apraxia; lesion in non dominant parietal lobe (right)
Corticosteroid and acyclovir
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

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

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24. How to prevent prevent frequency of MS exacerbation
Aspirin - control HTN and swallow eval before giving any oral meds
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

25. 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
Obturator n lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Femoral n lesion

26. How to tx acute exacerbation of MS
Despite the term neuroma they arise from schwann cells - schwanoma
90% of right handed and 60% of left handed persons; speech and language function
Aspirin - control HTN and swallow eval before giving any oral meds
High dose IV methyleprednisone;

27. contraindication of sumatripta
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease
Antitoxin

28. 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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Propranolol or primidone
<20; if patient scores >25 benign forgetfulness

29. How to tx stroke patient came after 6h
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aspirin - control HTN and swallow eval before giving any oral meds

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

31. what drug is used to extend effects of levodopa
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
20%
Entacapone - COMT inhibitor

32. Patient with carbamazepine; What should be advice?
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

33. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
<20; if patient scores >25 benign forgetfulness
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

34. How to manage stroke patient came within 4 hours
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Femoral n lesion
High dose IV methyleprednisone;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

35. 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aphasia - neglect - agnosia - acalculia etc
Propranolol or primidone

36. MG
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acetylecholinersterase inhibitors
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aphasia - neglect - agnosia - acalculia etc

37. How to confirm braindeath?
Femoral n lesion
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.
Acetylecholinersterase inhibitors
EPV - campylobacter - HSV

38. prodrome of vasovagal syncope
Vitamin B12 deficiency
Tunnel vision - diaphoresis - nausea - pallor
MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

39. When to start fibrinolytic therapy in stroke patient?
Coronary artery disease
Spastic paraparesis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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

40. 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
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
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

41. What mmse score suggest dementia
Cerebellar lesion
<20; if patient scores >25 benign forgetfulness
Diabetes insipidus
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

42. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

43. 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
Obturator n lesion
Clonidine will take care both high bp and withdrawal
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

44. earliest sign of phenytoin toxicity
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Not within 24 hours; give afte 24-48 hours if patient stable
Nystagmus on far lateral gaze

45. How to differentiate botulism from tick born paralysis - GBS and MG
MS
Botulism has descending paralysis in contrast othere have ascending paralysis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
90% of right handed and 60% of left handed persons; speech and language function

46. Unable to copy of matchstick - unable to dress up
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Construction apraxia; lesion in non dominant parietal lobe (right)

47. Should we tx htn in acute ischemic stroke

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48. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Tunnel vision - diaphoresis - nausea - pallor
MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency

49. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

50. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion
Entacapone - COMT inhibitor