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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. what drug is used to extend effects of levodopa
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Diabetes insipidus

2. How to confirm braindeath?
Tunnel vision - diaphoresis - nausea - pallor
Nystagmus on far lateral gaze
Obturator n lesion
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.

3. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable
Clonidine will take care both high bp and withdrawal
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

4. MG
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
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.
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

5. When to use dopamine agonist pramipexol in parkinson
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

6. Unable to copy of matchstick - unable to dress up
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)
MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

7. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

8. What is can be used cluster headache prevention
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Coronary artery disease

9. labyrinthitis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Tunnel vision - diaphoresis - nausea - pallor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Follows viral illness; vertigo - tinnitus - nausea. self limiting

10. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
Aphasia - neglect - agnosia - acalculia etc
Obturator n lesion

11. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Obturator n lesion
High dose IV methyleprednisone;

12. differentiate lewy body dementia and vascular dementia
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

13. How to perform apnea test
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; 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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Nystagmus on far lateral gaze
Vitamin B12 deficiency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

15. MMSE score of less than 24
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
82% specific for dementia
Entacapone - COMT inhibitor

16. differentiate wenicke and korsakoff
Difficulty in writing - calculating - distinguishing left and write
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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.

17. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Coronary artery disease
82% specific for dementia
Cerebral palsy; dx mri
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

18. How to differentiate medial and lateral pontine syndrome
Femoral n lesion
Aphasia - neglect - agnosia - acalculia etc
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
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;

19. anerior and anteriomedial thigh paresthesia - decreased DTR
Difficulty in writing - calculating - distinguishing left and write
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
Autospy gold standard
Femoral n lesion

20. How to manage stroke patient came within 4 hours
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

21. When to suspect traumatic LP
RBC count >6000
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Cerebral palsy; dx mri

22. dominant parietal lobe on the left side
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
90% of right handed and 60% of left handed persons; speech and language function
Cerebral palsy; dx mri
Coronary artery disease

23. differentiate picks and huntington
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
Obturator n lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency

24. How to differentiate medial and lateral medullary syndrome
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;
Myasthenia; due to autoantibodies against acetylecholine receptor;
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)

25. How to prevent prevent frequency of MS exacerbation
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
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function

26. Patient with carbamazepine; What should be advice?
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Reduced efficacy of OCP
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

27. Should we tx htn in acute ischemic stroke

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28. Tx of GBS
MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Femoral n lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

29. infections in GBS
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Cerebral palsy; dx mri
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

30. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Antitoxin
Aphasia - neglect - agnosia - acalculia etc

31. Tx of bells palsy
Normal pressure hydrocephalus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Corticosteroid and acyclovir
Myasthenia; due to autoantibodies against acetylecholine receptor;

32. cortical lesion
Femoral n lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Aphasia - neglect - agnosia - acalculia etc

33. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebral palsy; dx mri
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

34. When to start fibrinolytic therapy in stroke patient?
Tunnel vision - diaphoresis - nausea - pallor
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 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
90% of right handed and 60% of left handed persons; speech and language function

35. indication of plasmapheresis in GBS
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
90% of right handed and 60% of left handed persons; speech and language function
Entacapone - COMT inhibitor

36. dementia plus urinary incontinence
Normal pressure hydrocephalus
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

37. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Despite the term neuroma they arise from schwann cells - schwanoma
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Myasthenia; due to autoantibodies against acetylecholine receptor;

38. When to give aspirin when patient on tPA after stroke
It patient has electrolyte imbalance and hypothermia
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis
Not within 24 hours; give afte 24-48 hours if patient stable

39. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Distal lower motor neuron disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

40. When headache is presenting complaint of brain tumor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

41. botulism
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Antitoxin
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

42. GBS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe
IVIG and plasmapheresis

43. How to tx stroke patient came after 6h
Obturator n lesion
Aspirin - control HTN and swallow eval before giving any oral meds
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
Deficit in cranial nerve function

44. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Botulism has descending paralysis in contrast othere have ascending paralysis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

45. stroke with lower facial palsy - pronator drift despite on aspirin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Normal pressure hydrocephalus
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Aspirin - control HTN and swallow eval before giving any oral meds

46. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

47. How to differentiate parkinson and benign essential tremor
Aphasia - neglect - agnosia - acalculia etc
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Aspirin - control HTN and swallow eval before giving any oral meds

48. double vision at the end of day and ptosis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard
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.

49. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
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
Taper gradually to prevent seizure relapse

50. How to differentiate botulism from tick born paralysis - GBS and MG
Difficulty in writing - calculating - distinguishing left and write
Reduced efficacy of OCP
Botulism has descending paralysis in contrast othere have ascending paralysis
Nystagmus on far lateral gaze