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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 diffrentiate tick borne paralysis from GBS and spinal cord tumor
20%
Myasthenia; due to autoantibodies against acetylecholine receptor;
Aphasia - neglect - agnosia - acalculia etc
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

2. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Clonidine will take care both high bp and withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
EPV - campylobacter - HSV

3. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

4. How to tx acute exacerbation of MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Lesion in nondominant temporal lobe
High dose IV methyleprednisone;
Deficit in cranial nerve function

5. How to tx stroke patient came after 6h
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aspirin - control HTN and swallow eval before giving any oral meds
Cholinesterase inhibitor; and antiparkinsonism drugs

6. cortical lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Aphasia - neglect - agnosia - acalculia etc

7. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Diabetes insipidus
Distal lower motor neuron disease

8. When to give aspirin when patient on tPA after stroke
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acetylecholinersterase inhibitors
Not within 24 hours; give afte 24-48 hours if patient stable
Wernicke's encephalopathy; due to thiamine definition; medical emergency

9. How to differentiate dementias
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Lesion in nondominant temporal lobe

10. Unable to copy of matchstick - unable to dress up
Difficulty in writing - calculating - distinguishing left and write
Construction apraxia; lesion in non dominant parietal lobe (right)
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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

11. differentiate lewy body dementia and vascular dementia
EPV - campylobacter - HSV
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
Corticosteroid and acyclovir
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

12. botulism
Cholinesterase inhibitor; and antiparkinsonism drugs
90% of right handed and 60% of left handed persons; speech and language function
Antitoxin
Acetylecholinersterase inhibitors

13. Blood transfusion in hypothermia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Botulism has descending paralysis in contrast othere have ascending paralysis
Distal lower motor neuron disease

14. oligoclonal band in CSF
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Normal pressure hydrocephalus
20%
MS

15. labyrinthitis
Propranolol or primidone
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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.
Follows viral illness; vertigo - tinnitus - nausea. self limiting

16. How to perform apnea test
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
20%

17. dementia plus urinary incontinence
Spastic paraparesis
82% specific for dementia
Propranolol or primidone
Normal pressure hydrocephalus

18. 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
High dose IV methyleprednisone;
Obturator n lesion
Taper gradually to prevent seizure relapse

19. Tx of GBS
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Aphasia - neglect - agnosia - acalculia etc
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
90% of right handed and 60% of left handed persons; speech and language function

20. severe headache and high BP
Construction apraxia; lesion in non dominant parietal lobe (right)
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
82% specific for dementia

21. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Distal lower motor neuron disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

22. How to differentiate parkinson and benign essential tremor
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 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
Acetylecholinersterase inhibitors
Corticosteroid and acyclovir

23. lesion in dominant parietal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
RBC count >6000
Difficulty in writing - calculating - distinguishing left and write
Tunnel vision - diaphoresis - nausea - pallor

24. When to suspect traumatic LP
High dose IV methyleprednisone;
Myasthenia; due to autoantibodies against acetylecholine receptor;
Taper gradually to prevent seizure relapse
RBC count >6000

25. acoustic neuroma
Diabetes insipidus
Despite the term neuroma they arise from schwann cells - schwanoma
Botulism has descending paralysis in contrast othere have ascending paralysis
Autospy gold standard

26. How to tx lewy body dementia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs

27. infections in GBS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
EPV - campylobacter - HSV
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Nystagmus on far lateral gaze

28. How to differentiate medial and lateral pontine syndrome
90% of right handed and 60% of left handed persons; speech and language function
Antitoxin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

29. How to differentiate botulism from tick born paralysis - GBS and MG
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;
Botulism has descending paralysis in contrast othere have ascending paralysis
Coronary artery disease

30. Tx of bells palsy
Normal pressure hydrocephalus
Corticosteroid and acyclovir
82% specific for dementia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

31. What percent of dementia is reversible
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
20%
Obturator n lesion

32. impaired hepatic conjugation of billirubin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
High dose IV methyleprednisone;
Cerebral palsy; dx mri
Gilberts disease

33. 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
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

34. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Acetylecholinersterase inhibitors
Gilberts disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

35. women with unilateral eye pain; neurlogic symptoms here there at different times
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

36. When to use brain spect scintigraphy to confirm brain death
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
It patient has electrolyte imbalance and hypothermia
Acetylecholinersterase inhibitors
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. benign essential tremor
EPV - campylobacter - HSV
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
Propranolol or primidone
Cerebellar lesion

38. Why V12 deficient develop hypokalemia after tx with b12
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Vitamin B12 deficiency
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

39. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebellar lesion
20%
Distal lower motor neuron disease

40. 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.
It patient has electrolyte imbalance and hypothermia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Aspirin - control HTN and swallow eval before giving any oral meds

41. cluster headache
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in writing - calculating - distinguishing left and write
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
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

42. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
<20; if patient scores >25 benign forgetfulness
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Aphasia - neglect - agnosia - acalculia etc

43. How to differentiate medial and lateral medullary syndrome
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
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
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;

44. What is can be used cluster headache prevention
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
<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
Verapamil

45. impaired vibration and increased DTR
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Despite the term neuroma they arise from schwann cells - schwanoma
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Vitamin B12 deficiency

46. indication of plasmapheresis in GBS
Cholinesterase inhibitor; and antiparkinsonism drugs
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Autospy gold standard
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

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

48. 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
Propranolol or primidone
Clonidine will take care both high bp and withdrawal

49. When to use dopamine agonist pramipexol in parkinson
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
Antitoxin
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

50. How to stop antiepileptic drugs
Get up from chair walk a short distance turn around and sit; screening test for fall
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Lesion in nondominant temporal lobe
Taper gradually to prevent seizure relapse