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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. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
Corticosteroid and acyclovir

2. korsafoff psychosis
Coronary artery disease
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
Tunnel vision - diaphoresis - nausea - pallor

3. How to prevent prevent frequency of MS exacerbation
<20; if patient scores >25 benign forgetfulness
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Botulism has descending paralysis in contrast othere have ascending paralysis
90% of right handed and 60% of left handed persons; speech and language function

4. oligoclonal band in CSF
Antitoxin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Lesion in nondominant temporal lobe
MS

5. When to give aspirin when patient on tPA after stroke
MS
Not within 24 hours; give afte 24-48 hours if patient stable
Get up from chair walk a short distance turn around and sit; screening test for fall
Aphasia - neglect - agnosia - acalculia etc

6. What mmse score suggest dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
<20; if patient scores >25 benign forgetfulness
Taper gradually to prevent seizure relapse
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

7. MG
Acetylecholinersterase inhibitors
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Upright supine position
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

8. When to use brain spect scintigraphy to confirm brain death
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
It patient has electrolyte imbalance and hypothermia
Cholinesterase inhibitor; and antiparkinsonism drugs

9. How to differentiate parkinson and benign essential tremor
82% specific for dementia
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
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
It patient has electrolyte imbalance and hypothermia

10. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Femoral n lesion
Reduced efficacy of OCP
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

11. 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
Vitamin B12 deficiency
Propranolol or primidone

12. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Nystagmus on far lateral gaze
Normal pressure hydrocephalus
Cerebral palsy; dx mri

13. cortical lesion
Not within 24 hours; give afte 24-48 hours if patient stable
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

14. Unable to copy of matchstick - unable to dress up
Nystagmus on far lateral gaze
MS
Difficulty in writing - calculating - distinguishing left and write
Construction apraxia; lesion in non dominant parietal lobe (right)

15. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Vitamin B12 deficiency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds

16. How to tx lewy body dementia
Difficulty in writing - calculating - distinguishing left and write
Cholinesterase inhibitor; and antiparkinsonism drugs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Obturator n lesion

17. stroke with lower facial palsy - pronator drift despite on aspirin
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
<20; if patient scores >25 benign forgetfulness
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

18. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
It patient has electrolyte imbalance and hypothermia
Clonidine will take care both high bp and withdrawal
Myasthenia; due to autoantibodies against acetylecholine receptor;

19. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Cholinesterase inhibitor; and antiparkinsonism drugs
90% of right handed and 60% of left handed persons; speech and language function
EPV - campylobacter - HSV
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

20. GBS
IVIG and plasmapheresis
Diabetes insipidus
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;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

21. When to use dopamine agonist pramipexol in parkinson
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Taper gradually to prevent seizure relapse
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

22. impaired perception of complex sounds
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Upright supine position
Lesion in nondominant temporal lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

23. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Taper gradually to prevent seizure relapse
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;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

24. How to differentiate medial and lateral pontine syndrome
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
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
Corticosteroid and acyclovir
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

25. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
90% of right handed and 60% of left handed persons; speech and language function
MS
Difficulty in writing - calculating - distinguishing left and write

26. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

27. infections in GBS
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
Not within 24 hours; give afte 24-48 hours if patient stable
EPV - campylobacter - HSV

28. cluster headache
Acetylecholinersterase inhibitors
Construction apraxia; lesion in non dominant parietal lobe (right)
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
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

29. When to suspect traumatic LP
20%
RBC count >6000
Clonidine will take care both high bp and withdrawal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

30. indication of plasmapheresis in GBS
High dose IV methyleprednisone;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Normal pressure hydrocephalus

31. How to perform apnea test
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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
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

32. medial thigh sensory loss and weakness in addcution
EPV - campylobacter - HSV
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Vitamin B12 deficiency

33. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebral palsy; dx mri

34. at first tingling in toes and feet then weakness in extremities
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
It patient has electrolyte imbalance and hypothermia

35. Should we tx htn in acute ischemic stroke

36. How to differentiate dementias
Normal pressure hydrocephalus
Aphasia - neglect - agnosia - acalculia etc
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

37. How to tx stroke patient came after 6h
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aspirin - control HTN and swallow eval before giving any oral meds
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

38. differentiate lewy body dementia and vascular dementia
EPV - campylobacter - HSV
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
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

39. best diagnosis for parkinsonim
Distal lower motor neuron disease
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Autospy gold standard

40. How to confirm braindeath?
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Myasthenia; due to autoantibodies against acetylecholine receptor;
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.

41. 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
Femoral n lesion
Normal pressure hydrocephalus
MS

42. 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
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

43. impaired vibration and increased DTR
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Vitamin B12 deficiency
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

44. Tx of bells palsy
Corticosteroid and acyclovir
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

45. 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
Clonidine will take care both high bp and withdrawal
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
Femoral n lesion

46. phenytoin and OCP
Taper gradually to prevent seizure relapse
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP
Distal lower motor neuron disease

47. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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; if patient scores >25 benign forgetfulness
Clonidine will take care both high bp and withdrawal
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

48. impaired hepatic conjugation of billirubin
Gilberts disease
Verapamil
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Nystagmus on far lateral gaze

49. How to differentiate botulism from tick born paralysis - GBS and MG
Get up from chair walk a short distance turn around and sit; screening test for fall
Botulism has descending paralysis in contrast othere have ascending paralysis
Spastic paraparesis
Nystagmus on far lateral gaze

50. Acute onset of left arm weakness
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acetylecholinersterase inhibitors