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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. medial thigh sensory loss and weakness in addcution
High dose IV methyleprednisone;
Obturator n lesion
Femoral n lesion
Difficulty in writing - calculating - distinguishing left and write

2. differentiate wenicke and korsakoff
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
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

3. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Reduced efficacy of OCP

4. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Lesion in nondominant temporal lobe
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Propranolol or primidone

5. excessive elevation of legs during walking (toe touch floor earlier than heels)
High dose IV methyleprednisone;
Distal lower motor neuron disease
20%
Vitamin B12 deficiency

6. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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;

7. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Get up from chair walk a short distance turn around and sit; screening test for fall
Acetylecholinersterase inhibitors
Follows viral illness; vertigo - tinnitus - nausea. self limiting

8. How to confirm braindeath?
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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.
Wernicke's encephalopathy; due to thiamine definition; medical emergency

9. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Diabetes insipidus

10. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone

11. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Not within 24 hours; give afte 24-48 hours if patient stable
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cerebellar lesion
IVIG and plasmapheresis

12. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Lesion in nondominant temporal lobe
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

13. stroke with lower facial palsy - pronator drift despite on aspirin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Clonidine will take care both high bp and withdrawal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

14. impaired vibration and increased DTR
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Vitamin B12 deficiency
Taper gradually to prevent seizure relapse
Acetylecholinersterase inhibitors

15. How to manage stroke patient came within 4 hours
RBC count >6000
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
High dose IV methyleprednisone;
Entacapone - COMT inhibitor

16. How to differentiate parkinson and benign essential tremor
Get up from chair walk a short distance turn around and sit; screening test for fall
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Antitoxin

17. dominant parietal lobe on the left side
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
90% of right handed and 60% of left handed persons; speech and language function
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
RBC count >6000

18. What percent of dementia is reversible
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
20%
Deficit in cranial nerve function

19. anerior and anteriomedial thigh paresthesia - decreased DTR
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.
Construction apraxia; lesion in non dominant parietal lobe (right)
Femoral n lesion
Clonidine will take care both high bp and withdrawal

20. what drug is used to extend effects of levodopa
IVIG and plasmapheresis
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
Entacapone - COMT inhibitor

21. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
RBC count >6000
Despite the term neuroma they arise from schwann cells - schwanoma
Wernicke's encephalopathy; due to thiamine definition; medical emergency

22. prodrome of vasovagal syncope
Autospy gold standard
Acetylecholinersterase inhibitors
Obturator n lesion
Tunnel vision - diaphoresis - nausea - pallor

23. dementia plus urinary incontinence
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Clonidine will take care both high bp and withdrawal
IVIG and plasmapheresis
Normal pressure hydrocephalus

24. How to tx lewy body dementia
Vitamin B12 deficiency
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Get up from chair walk a short distance turn around and sit; screening test for fall

25. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
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

26. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Propranolol or primidone
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

27. contraindication of sumatripta
Aspirin - control HTN and swallow eval before giving any oral meds
82% specific for dementia
Coronary artery disease
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

28. acoustic neuroma
Lesion in nondominant temporal lobe
Despite the term neuroma they arise from schwann cells - schwanoma
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

29. Patient with carbamazepine; What should be advice?
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Tunnel vision - diaphoresis - nausea - pallor

30. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri
Upright supine position
Distal lower motor neuron disease

31. How to tx stroke patient came after 6h
Cerebral palsy; dx mri
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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;
Aspirin - control HTN and swallow eval before giving any oral meds

32. impaired perception of complex sounds
Get up from chair walk a short distance turn around and sit; screening test for fall
Lesion in nondominant temporal lobe
Diabetes insipidus
Verapamil

33. craniopharyngioma
Diabetes insipidus
Distal lower motor neuron disease
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
Deficit in cranial nerve function

34. Why V12 deficient develop hypokalemia after tx with b12
Aspirin - control HTN and swallow eval before giving any oral meds
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;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

35. Unable to copy of matchstick - unable to dress up
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Taper gradually to prevent seizure relapse

36. How to stop antiepileptic drugs
Gilberts disease
Taper gradually to prevent seizure relapse
Vitamin B12 deficiency
Normal pressure hydrocephalus

37. How to prevent prevent frequency of MS exacerbation
Construction apraxia; lesion in non dominant parietal lobe (right)
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Nystagmus on far lateral gaze
Myasthenia; due to autoantibodies against acetylecholine receptor;

38. severe headache and high BP
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

39. infections in GBS
EPV - campylobacter - HSV
Despite the term neuroma they arise from schwann cells - schwanoma
Coronary artery disease
Get up from chair walk a short distance turn around and sit; screening test for fall

40. brain stem lesion
Verapamil
Corticosteroid and acyclovir
Deficit in cranial nerve function
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

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

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42. differentiate picks and huntington
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebellar lesion
Entacapone - COMT inhibitor
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

43. at first tingling in toes and feet then weakness in extremities
Autospy gold standard
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

44. GBS
IVIG and plasmapheresis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

45. cluster headache
Nystagmus on far lateral gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

46. phenytoin and OCP
Deficit in cranial nerve function
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.
Reduced efficacy of OCP
Difficulty in writing - calculating - distinguishing left and write

47. When to give aspirin when patient on tPA after stroke
Verapamil
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Not within 24 hours; give afte 24-48 hours if patient stable

48. korsafoff psychosis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Not within 24 hours; give afte 24-48 hours if patient stable
Aphasia - neglect - agnosia - acalculia etc

49. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000
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. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Antitoxin
Myasthenia; due to autoantibodies against acetylecholine receptor;