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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. prodrome of vasovagal syncope
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable
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

2. How to differentiate dementias
It patient has electrolyte imbalance and hypothermia
<20; if patient scores >25 benign forgetfulness
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Despite the term neuroma they arise from schwann cells - schwanoma

3. impaired vibration and increased DTR
Vitamin B12 deficiency
Clonidine will take care both high bp and withdrawal
High dose IV methyleprednisone;
Construction apraxia; lesion in non dominant parietal lobe (right)

4. botulism
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
Antitoxin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

5. How to tx lewy body dementia
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cholinesterase inhibitor; and antiparkinsonism drugs
20%
Verapamil

6. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Femoral n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

7. Why V12 deficient develop hypokalemia after tx with b12
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
Entacapone - COMT inhibitor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

8. How to manage stroke patient came within 4 hours
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Diabetes insipidus

9. MMSE score of less than 24
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.
82% specific for dementia
Clonidine will take care both high bp and withdrawal
Upright supine position

10. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Propranolol or primidone
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir

11. When to suspect traumatic LP
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
RBC count >6000
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
Construction apraxia; lesion in non dominant parietal lobe (right)

12. infections in GBS
RBC count >6000
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc
High dose IV methyleprednisone;

13. 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
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

14. Should we tx htn in acute ischemic stroke

15. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Antitoxin

16. MG
Acetylecholinersterase inhibitors
Clonidine will take care both high bp and withdrawal
90% of right handed and 60% of left handed persons; speech and language function
Corticosteroid and acyclovir

17. What is pronator drift
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

18. How to differentiate parkinson and benign essential tremor
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
Taper gradually to prevent seizure relapse
Cerebellar lesion

19. How to differentiate medial and lateral pontine syndrome
It patient has electrolyte imbalance and hypothermia
High dose IV methyleprednisone;
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
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

20. How to confirm braindeath?
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Vitamin B12 deficiency
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.
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

21. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

22. anerior and anteriomedial thigh paresthesia - decreased DTR
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Obturator n lesion
Femoral n lesion

23. When to use dopamine agonist pramipexol in parkinson
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

24. severe headache and high BP
Difficulty in writing - calculating - distinguishing left and write
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
Clonidine will take care both high bp and withdrawal

25. women with unilateral eye pain; neurlogic symptoms here there at different times
Clonidine will take care both high bp and withdrawal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Despite the term neuroma they arise from schwann cells - schwanoma
Aspirin - control HTN and swallow eval before giving any oral meds

26. differentiate lewy body dementia and vascular 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
Obturator n lesion
High dose IV methyleprednisone;
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

27. impaired perception of complex sounds
Taper gradually to prevent seizure relapse
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.
Propranolol or primidone
Lesion in nondominant temporal lobe

28. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
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;
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.
Coronary artery disease

29. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
High dose IV methyleprednisone;
Construction apraxia; lesion in non dominant parietal lobe (right)
Cholinesterase inhibitor; and antiparkinsonism drugs
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

30. brain stem lesion
Deficit in cranial nerve function
<20; if patient scores >25 benign forgetfulness
Verapamil
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

31. dominant parietal lobe on the left side
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Femoral n lesion
90% of right handed and 60% of left handed persons; speech and language function

32. medial thigh sensory loss and weakness in addcution
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
Obturator n lesion
Reduced efficacy of OCP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

33. craniopharyngioma
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
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
Diabetes insipidus
Lesion in nondominant temporal lobe

34. What is can be used cluster headache prevention
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Verapamil

35. How to stop antiepileptic drugs
Entacapone - COMT inhibitor
Deficit in cranial nerve function
Taper gradually to prevent seizure relapse
Cholinesterase inhibitor; and antiparkinsonism drugs

36. earliest sign of phenytoin toxicity
Obturator n lesion
Lesion in nondominant temporal lobe
Difficulty in writing - calculating - distinguishing left and write
Nystagmus on far lateral gaze

37. benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Propranolol or primidone
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Gilberts disease

38. double vision at the end of day and ptosis
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
Construction apraxia; lesion in non dominant parietal lobe (right)
High dose IV methyleprednisone;

39. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

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

41. How to differentiate traumatic LP and 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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

42. labyrinthitis
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
Despite the term neuroma they arise from schwann cells - schwanoma
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Wernicke's encephalopathy; due to thiamine definition; medical emergency

43. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Acetylecholinersterase inhibitors

44. 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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
<20; if patient scores >25 benign forgetfulness
Aphasia - neglect - agnosia - acalculia etc

45. How to differentiate botulism from tick born paralysis - GBS and MG
90% of right handed and 60% of left handed persons; speech and language function
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Get up from chair walk a short distance turn around and sit; screening test for fall

46. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Get up from chair walk a short distance turn around and sit; screening test for fall
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

47. Patient with carbamazepine; What should be advice?
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acetylecholinersterase inhibitors
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
Femoral n lesion

48. contraindication of sumatripta
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Entacapone - COMT inhibitor
Coronary artery disease
Cholinesterase inhibitor; and antiparkinsonism drugs

49. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; 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;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

50. 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
Gilberts disease
Obturator n lesion
RBC count >6000