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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. botulism
Antitoxin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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;

2. Should we tx htn in acute ischemic stroke

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3. When to start fibrinolytic therapy in stroke patient?
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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

4. dementia plus urinary incontinence
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Not within 24 hours; give afte 24-48 hours if patient stable
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Normal pressure hydrocephalus

5. differentiate lewy body dementia and vascular dementia
Despite the term neuroma they arise from schwann cells - schwanoma
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Femoral n lesion

6. best diagnosis for parkinsonim
Autospy gold standard
Gilberts disease
Normal pressure hydrocephalus
Difficulty in writing - calculating - distinguishing left and write

7. brain stem lesion
Despite the term neuroma they arise from schwann cells - schwanoma
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.
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Deficit in cranial nerve function

8. stroke with lower facial palsy - pronator drift despite on aspirin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

9. Unable to copy of matchstick - unable to dress up
MS
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)
Cerebral palsy; dx mri

10. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Botulism has descending paralysis in contrast othere have ascending paralysis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal
Reduced efficacy of OCP

11. When to suspect traumatic LP
EPV - campylobacter - HSV
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
RBC count >6000

12. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Upright supine position
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

13. excessive elevation of legs during walking (toe touch floor earlier than heels)
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Aphasia - neglect - agnosia - acalculia etc
Aspirin - control HTN and swallow eval before giving any oral meds
Distal lower motor neuron disease

14. How to differentiate parkinson and benign essential tremor
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
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

15. anerior and anteriomedial thigh paresthesia - decreased DTR
Deficit in cranial nerve function
Femoral n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
IVIG and plasmapheresis

16. What is can be used cluster headache prevention
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
Verapamil
Upright supine position

17. 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
90% of right handed and 60% of left handed persons; speech and language function
Corticosteroid and acyclovir
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

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

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19. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

20. differentiate picks and huntington
Entacapone - COMT inhibitor
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 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
Verapamil

21. Patient with carbamazepine; What should be advice?
Spastic paraparesis
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

22. Blood transfusion in hypothermia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

23. Tx of GBS
Corticosteroid and acyclovir
Femoral n lesion
Upright supine position
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

24. cortical lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Aphasia - neglect - agnosia - acalculia etc
Tunnel vision - diaphoresis - nausea - pallor
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

25. How to tx lewy body dementia
Autospy gold standard
EPV - campylobacter - HSV
Cholinesterase inhibitor; and antiparkinsonism drugs
90% of right handed and 60% of left handed persons; speech and language function

26. get up and go test
Construction apraxia; lesion in non dominant parietal lobe (right)
Get up from chair walk a short distance turn around and sit; screening test for fall
Nystagmus on far lateral gaze
Upright supine position

27. women with unilateral eye pain; neurlogic symptoms here there at different times
MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Deficit in cranial nerve function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

28. earliest sign of phenytoin toxicity
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.
Nystagmus on far lateral gaze
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

29. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Spastic paraparesis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Femoral n lesion

30. How to tx acute exacerbation of MS
Aspirin - control HTN and swallow eval before giving any oral meds
Tunnel vision - diaphoresis - nausea - pallor
Cerebral palsy; dx mri
High dose IV methyleprednisone;

31. 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
Acetylecholinersterase inhibitors
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

32. MMSE score of less than 24
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;
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
82% specific for dementia

33. severe headache and high BP
Aspirin - control HTN and swallow eval before giving any oral meds
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
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

34. How to manage stroke patient came within 4 hours
RBC count >6000
Coronary artery disease
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

35. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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
MS

36. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Nystagmus on far lateral gaze
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

37. impaired perception of complex sounds
Obturator n lesion
Lesion in nondominant temporal lobe
Spastic paraparesis
Wernicke's encephalopathy; due to thiamine definition; medical emergency

38. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Antitoxin
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Lesion in nondominant temporal lobe

39. infections in GBS
Difficulty in writing - calculating - distinguishing left and write
Vitamin B12 deficiency
Cholinesterase inhibitor; and antiparkinsonism drugs
EPV - campylobacter - HSV

40. indication of plasmapheresis in GBS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

41. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
RBC count >6000

42. How to stop antiepileptic drugs
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Taper gradually to prevent seizure relapse
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
<20; if patient scores >25 benign forgetfulness

43. differentiate wenicke and korsakoff
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

44. double vision at the end of day and ptosis
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

45. prodrome of vasovagal syncope
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Tunnel vision - diaphoresis - nausea - pallor

46. 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
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia

47. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acetylecholinersterase inhibitors
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

48. What mmse score suggest dementia
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
RBC count >6000
82% specific for dementia
<20; if patient scores >25 benign forgetfulness

49. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Myasthenia; due to autoantibodies against acetylecholine receptor;
Reduced efficacy of OCP
Acetylecholinersterase inhibitors

50. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Tunnel vision - diaphoresis - nausea - pallor