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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. infections in GBS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
EPV - campylobacter - HSV
Autospy gold standard
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

2. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

3. contraindication of sumatripta
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Deficit in cranial nerve function
Coronary artery disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

4. How to manage stroke patient came within 4 hours
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Despite the term neuroma they arise from schwann cells - schwanoma

5. what drug is used to extend effects of levodopa
Coronary artery disease
Entacapone - COMT inhibitor
Propranolol or primidone
Gilberts disease

6. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
20%
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
Femoral n lesion

7. When to use brain spect scintigraphy to confirm brain death
Femoral n lesion
It patient has electrolyte imbalance and hypothermia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

8. How to differentiate traumatic LP and SAH
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

9. lesion in dominant tempora lobe
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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.
Diabetes insipidus

10. impaired perception of complex sounds
Obturator n lesion
Lesion in nondominant temporal lobe
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
It patient has electrolyte imbalance and hypothermia

11. Blood transfusion in hypothermia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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;
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

12. When to start fibrinolytic therapy in stroke patient?
Lesion in nondominant temporal lobe
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

13. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Antitoxin
Gilberts disease
Tunnel vision - diaphoresis - nausea - pallor
Cerebellar lesion

14. How to tx lewy body dementia
82% specific for dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Entacapone - COMT inhibitor

15. How to confirm braindeath?
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Reduced efficacy of OCP
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.
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

16. Tx of GBS
Cholinesterase inhibitor; and antiparkinsonism drugs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

17. 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;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia
Lesion in nondominant temporal lobe

18. dominant parietal lobe on the left side
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
RBC count >6000
Vitamin B12 deficiency
90% of right handed and 60% of left handed persons; speech and language function

19. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Nystagmus on far lateral gaze
Verapamil
It patient has electrolyte imbalance and hypothermia

20. benign essential tremor
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone
Aphasia - neglect - agnosia - acalculia etc
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

21. get up and go test
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
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

22. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Gilberts disease
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
Spastic paraparesis
Cerebral palsy; dx mri

23. Patient with carbamazepine; What should be advice?
Cerebellar lesion
Upright supine position
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
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;

24. prodrome of vasovagal syncope
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tunnel vision - diaphoresis - nausea - pallor
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

25. MG
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
Acetylecholinersterase inhibitors
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
Despite the term neuroma they arise from schwann cells - schwanoma

26. impaired vibration and increased DTR
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Spontaneous remission; admit if suspected and monitor pulse ox for 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;
Vitamin B12 deficiency

27. How to differentiate parkinson and benign essential tremor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
IVIG and plasmapheresis
Cholinesterase inhibitor; and antiparkinsonism drugs
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

28. Unable to copy of matchstick - unable to dress up
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
Distal lower motor neuron disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

29. cluster headache
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
82% specific for dementia

30. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
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
Taper gradually to prevent seizure relapse
Spastic paraparesis

31. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Corticosteroid and acyclovir
Clonidine will take care both high bp and withdrawal
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
High dose IV methyleprednisone;

32. at first tingling in toes and feet then weakness in extremities
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

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

34. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

35. botulism
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Antitoxin
Upright supine position

36. phenytoin and OCP
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aspirin - control HTN and swallow eval before giving any oral meds
High dose IV methyleprednisone;
Reduced efficacy of OCP

37. How to tx acute exacerbation of MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cerebral palsy; dx mri
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
High dose IV methyleprednisone;

38. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

39. lesion in dominant parietal lobe
Aphasia - neglect - agnosia - acalculia etc
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write
Get up from chair walk a short distance turn around and sit; screening test for fall

40. When to give aspirin when patient on tPA after stroke
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Not within 24 hours; give afte 24-48 hours if patient stable
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion

41. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Diabetes insipidus
Gilberts disease
Spastic paraparesis
Aspirin - control HTN and swallow eval before giving any oral meds

42. stroke with lower facial palsy - pronator drift despite on aspirin
Deficit in cranial nerve function
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cholinesterase inhibitor; and antiparkinsonism drugs

43. double vision at the end of day and ptosis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard

44. impaired hepatic conjugation of billirubin
Gilberts 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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Distal lower motor neuron disease

45. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
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
Despite the term neuroma they arise from schwann cells - schwanoma

46. What percent of dementia is reversible
20%
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
EPV - campylobacter - HSV

47. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

48. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Propranolol or primidone
Upright supine position
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

49. Tx of bells palsy
IVIG and plasmapheresis
Lesion in nondominant temporal lobe
Corticosteroid and acyclovir
90% of right handed and 60% of left handed persons; speech and language function

50. women with unilateral eye pain; neurlogic symptoms here there at different times
<20; if patient scores >25 benign forgetfulness
Diabetes insipidus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS