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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 manage stroke patient came within 4 hours
RBC count >6000
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

2. medial thigh sensory loss and weakness in addcution
Obturator n lesion
IVIG and plasmapheresis
Spastic paraparesis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

3. women with unilateral eye pain; neurlogic symptoms here there at different times
Not within 24 hours; give afte 24-48 hours if patient stable
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Femoral n lesion

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

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5. What mmse score suggest dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
<20; if patient scores >25 benign forgetfulness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
82% specific for dementia

6. earliest sign of phenytoin toxicity
Upright supine position
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Nystagmus on far lateral gaze
EPV - campylobacter - HSV

7. impaired hepatic conjugation of billirubin
Gilberts disease
Tunnel vision - diaphoresis - nausea - pallor
It patient has electrolyte imbalance and hypothermia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

8. How to differentiate medial and lateral pontine syndrome
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
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.
Get up from chair walk a short distance turn around and sit; screening test for fall
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

9. 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
Despite the term neuroma they arise from schwann cells - schwanoma
IVIG and plasmapheresis
EPV - campylobacter - HSV

10. differentiate picks and huntington
<20; if patient scores >25 benign forgetfulness
It patient has electrolyte imbalance and hypothermia
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
Antitoxin

11. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Lesion in nondominant temporal lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Clonidine will take care both high bp and withdrawal

12. When headache is presenting complaint of brain tumor
Coronary artery disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Lesion in nondominant temporal lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

13. How to prevent prevent frequency of MS exacerbation
Cerebellar lesion
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
Distal lower motor neuron disease

14. 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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
20%

15. Tx of GBS
Coronary artery disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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

16. MMSE score of less than 24
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Femoral n lesion
82% specific for dementia
Aspirin - control HTN and swallow eval before giving any oral meds

17. cortical lesion
Not within 24 hours; give afte 24-48 hours if patient stable
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.
Aphasia - neglect - agnosia - acalculia etc
Nystagmus on far lateral gaze

18. Patient with carbamazepine; What should be advice?
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
20%
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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

19. 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
Despite the term neuroma they arise from schwann cells - schwanoma
Taper gradually to prevent seizure relapse
Diabetes insipidus

20. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar 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
Gilberts disease
Spastic paraparesis

21. botulism
Autospy gold standard
Antitoxin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

22. Acute onset of left arm weakness
Deficit in cranial nerve function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cholinesterase inhibitor; and antiparkinsonism drugs
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;

23. double vision at the end of day and ptosis
Spastic paraparesis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Femoral n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting

24. 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
Entacapone - COMT inhibitor
High dose IV methyleprednisone;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

25. labyrinthitis
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma
82% specific for dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting

26. 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
Gilberts disease
Upright supine position
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

27. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Gilberts disease
Corticosteroid and acyclovir
Obturator n lesion

28. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Vitamin B12 deficiency
90% of right handed and 60% of left handed persons; speech and language function

29. 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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Spastic paraparesis
Verapamil

30. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Distal lower motor neuron disease
Botulism has descending paralysis in contrast othere have ascending paralysis

31. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

32. When to suspect traumatic LP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

33. contraindication of sumatripta
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
Coronary artery disease
Diabetes insipidus
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

34. indication of plasmapheresis in GBS
Corticosteroid and acyclovir
EPV - campylobacter - HSV
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

35. When to use dopamine agonist pramipexol in parkinson
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
EPV - campylobacter - HSV
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

36. differentiate lewy body dementia and vascular dementia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
82% specific for dementia
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
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

37. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Upright supine position
EPV - campylobacter - HSV
Deficit in cranial nerve function

38. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Diabetes insipidus
Femoral n lesion
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
Upright supine position

39. impaired vibration and increased DTR
Construction apraxia; lesion in non dominant parietal lobe (right)
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Aspirin - control HTN and swallow eval before giving any oral meds
Vitamin B12 deficiency

40. lesion in dominant tempora lobe
Taper gradually to prevent seizure relapse
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
High dose IV methyleprednisone;

41. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Reduced efficacy of OCP

42. How to tx acute exacerbation of MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Spastic paraparesis
High dose IV methyleprednisone;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

43. GBS
It patient has electrolyte imbalance and hypothermia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
IVIG and plasmapheresis
Botulism has descending paralysis in contrast othere have ascending paralysis

44. dementia plus urinary incontinence
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Normal pressure hydrocephalus
MS

45. What bp med to be given in a patient with high bp and signs of opioid withdrawal
90% of right handed and 60% of left handed persons; speech and language function
Clonidine will take care both high bp and withdrawal
Entacapone - COMT inhibitor
Not within 24 hours; give afte 24-48 hours if patient stable

46. stroke with lower facial palsy - pronator drift despite on aspirin
MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

47. MG
Acetylecholinersterase inhibitors
Diabetes insipidus
Obturator n lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

48. Tx of bells palsy
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
Despite the term neuroma they arise from schwann cells - schwanoma
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir

49. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Clonidine will take care both high bp and withdrawal

50. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Propranolol or primidone
High dose IV methyleprednisone;
90% of right handed and 60% of left handed persons; speech and language function