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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. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebral palsy; dx mri
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

2. craniopharyngioma
Normal pressure hydrocephalus
Diabetes insipidus
EPV - campylobacter - HSV
Upright supine position

3. impaired perception of complex sounds
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Lesion in nondominant temporal lobe

4. How to stop antiepileptic drugs
Distal lower motor neuron disease
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Taper gradually to prevent seizure relapse
Nystagmus on far lateral gaze

5. How to differentiate dementias
Difficulty in writing - calculating - distinguishing left and write
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Spastic paraparesis
Propranolol or primidone

6. How to differentiate botulism from tick born paralysis - GBS and MG
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Botulism has descending paralysis in contrast othere have ascending paralysis
Taper gradually to prevent seizure relapse
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

7. oligoclonal band in CSF
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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;

8. What is can be used cluster headache prevention
Antitoxin
Verapamil
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Not within 24 hours; give afte 24-48 hours if patient stable

9. phenytoin and OCP
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Reduced efficacy of OCP
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

10. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Difficulty in writing - calculating - distinguishing left and write
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

11. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tunnel vision - diaphoresis - nausea - pallor
Entacapone - COMT inhibitor

12. When to give aspirin when patient on tPA after stroke
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Not within 24 hours; give afte 24-48 hours if patient stable
82% specific for dementia
Botulism has descending paralysis in contrast othere have ascending paralysis

13. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion
Aphasia - neglect - agnosia - acalculia etc
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

14. benign essential tremor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Propranolol or primidone
Verapamil
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

15. botulism
RBC count >6000
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
Antitoxin
Taper gradually to prevent seizure relapse

16. MMSE score of less than 24
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
82% specific for dementia
Nystagmus on far lateral gaze
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

17. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

18. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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;
Spastic paraparesis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

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

20. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Myasthenia; due to autoantibodies against acetylecholine receptor;
Despite the term neuroma they arise from schwann cells - schwanoma

21. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
It patient has electrolyte imbalance and hypothermia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

22. When to start fibrinolytic therapy in stroke patient?
Normal pressure hydrocephalus
Aphasia - neglect - agnosia - acalculia etc
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Acetylecholinersterase inhibitors

23. 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
Tunnel vision - diaphoresis - nausea - pallor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

24. When to suspect traumatic LP
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000
Lesion in nondominant temporal lobe
Deficit in cranial nerve function

25. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

26. Blood transfusion in hypothermia
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
82% specific for dementia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

27. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Normal pressure hydrocephalus
Construction apraxia; lesion in non dominant parietal lobe (right)
Follows viral illness; vertigo - tinnitus - nausea. self limiting

28. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
High dose IV methyleprednisone;
Upright supine position
Femoral n lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

29. Tx of bells palsy
Distal lower motor neuron disease
Femoral n lesion
IVIG and plasmapheresis
Corticosteroid and acyclovir

30. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Propranolol or primidone
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.
Gilberts disease

31. GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Botulism has descending paralysis in contrast othere have ascending paralysis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
IVIG and plasmapheresis

32. How to differentiate parkinson and benign essential tremor
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
IVIG and plasmapheresis
Lesion in nondominant temporal lobe

33. infections in GBS
Coronary artery disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
EPV - campylobacter - HSV
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

34. get up and go test
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Botulism has descending paralysis in contrast othere have ascending paralysis

35. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Cerebral palsy; dx mri
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

36. How to tx lewy body dementia
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
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
Cholinesterase inhibitor; and antiparkinsonism drugs
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

37. Tx of GBS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebral palsy; dx mri
Cholinesterase inhibitor; and antiparkinsonism drugs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

38. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

39. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

40. When headache is presenting complaint of brain tumor
Normal pressure hydrocephalus
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
20%

41. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Clonidine will take care both high bp and withdrawal
20%
Difficulty in writing - calculating - distinguishing left and write

42. differentiate wenicke and korsakoff
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting

43. Acute onset of left arm weakness
Botulism has descending paralysis in contrast othere have ascending paralysis
Cholinesterase inhibitor; and antiparkinsonism drugs
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

44. best diagnosis for parkinsonim
Autospy gold standard
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

45. impaired vibration and increased DTR
Vitamin B12 deficiency
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%
Cerebral palsy; dx mri

46. indication of plasmapheresis in GBS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

47. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aphasia - neglect - agnosia - acalculia etc

48. earliest sign of phenytoin toxicity
Reduced efficacy of OCP
Taper gradually to prevent seizure relapse
Myasthenia; due to autoantibodies against acetylecholine receptor;
Nystagmus on far lateral gaze

49. Why V12 deficient develop hypokalemia after tx with b12
Not within 24 hours; give afte 24-48 hours if patient stable
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Aspirin - control HTN and swallow eval before giving any oral meds

50. What percent of dementia is reversible
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MS
Tunnel vision - diaphoresis - nausea - pallor