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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. When to use brain spect scintigraphy to confirm brain death
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
Aphasia - neglect - agnosia - acalculia etc
It patient has electrolyte imbalance and hypothermia
Obturator n lesion

2. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Difficulty in writing - calculating - distinguishing left and write
Aphasia - neglect - agnosia - acalculia etc
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

3. Tx of bells palsy
Corticosteroid and acyclovir
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS
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

4. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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.
Spastic paraparesis

5. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Construction apraxia; lesion in non dominant parietal lobe (right)
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
It patient has electrolyte imbalance and hypothermia

6. What bp med to be given in a patient with high bp and signs of opioid withdrawal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Clonidine will take care both high bp and withdrawal

7. How to stop antiepileptic drugs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Taper gradually to prevent seizure relapse
Lesion in nondominant temporal lobe

8. double vision at the end of day and ptosis
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
Not within 24 hours; give afte 24-48 hours if patient stable
Aspirin - control HTN and swallow eval before giving any oral meds
Myasthenia; due to autoantibodies against acetylecholine receptor;

9. differentiate wenicke and korsakoff
Normal pressure hydrocephalus
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;
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
90% of right handed and 60% of left handed persons; speech and language function

10. What percent of dementia is reversible
Get up from chair walk a short distance turn around and sit; screening test for fall
20%
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Diabetes insipidus

11. indication of plasmapheresis in GBS
Normal pressure hydrocephalus
Tunnel vision - diaphoresis - nausea - pallor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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.

12. How to differentiate traumatic LP and SAH
Botulism has descending paralysis in contrast othere have ascending paralysis
Diabetes insipidus
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS

13. phenytoin and OCP
RBC count >6000
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
Reduced efficacy of OCP

14. get up and go test
Myasthenia; due to autoantibodies against acetylecholine receptor;
Normal pressure hydrocephalus
Get up from chair walk a short distance turn around and sit; screening test for fall
Autospy gold standard

15. korsafoff psychosis
Deficit in cranial nerve function
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Verapamil
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

16. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Spastic paraparesis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

17. How to tx acute exacerbation of MS
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
High dose IV methyleprednisone;
Gilberts disease

18. best diagnosis for parkinsonim
Autospy gold standard
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Construction apraxia; lesion in non dominant parietal lobe (right)
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

19. infections in GBS
EPV - campylobacter - HSV
IVIG and plasmapheresis
Verapamil
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

20. Blood transfusion in hypothermia
Femoral n lesion
Despite the term neuroma they arise from schwann cells - schwanoma
Vitamin B12 deficiency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

21. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Entacapone - COMT inhibitor
Upright supine position
Cerebellar lesion
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

22. craniopharyngioma
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

23. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Construction apraxia; lesion in non dominant parietal lobe (right)
Autospy gold standard

24. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Autospy gold standard
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Reduced efficacy of OCP

25. 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
Difficulty in writing - calculating - distinguishing left and write
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

26. impaired hepatic conjugation of billirubin
Tunnel vision - diaphoresis - nausea - pallor
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
Gilberts disease
Aphasia - neglect - agnosia - acalculia etc

27. Why V12 deficient develop hypokalemia after tx with b12
Upright supine position
Lesion in nondominant temporal lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Diabetes insipidus

28. benign essential tremor
MS
Propranolol or primidone
Corticosteroid and acyclovir
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

29. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Lesion in nondominant temporal lobe
90% of right handed and 60% of left handed persons; speech and language function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

30. cortical lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tunnel vision - diaphoresis - nausea - pallor
Deficit in cranial nerve function
Aphasia - neglect - agnosia - acalculia etc

31. contraindication of sumatripta
Coronary artery disease
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cholinesterase inhibitor; and antiparkinsonism drugs
Deficit in cranial nerve function

32. What is can be used cluster headache prevention
Spastic paraparesis
Verapamil
It patient has electrolyte imbalance and hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

33. Tx of GBS
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
EPV - campylobacter - HSV
Lesion in nondominant temporal lobe

34. How to differentiate medial and lateral pontine syndrome
Autospy gold standard
Reduced efficacy of OCP
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
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

35. MG
Acetylecholinersterase inhibitors
Reduced efficacy of OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Corticosteroid and acyclovir

36. When to start fibrinolytic therapy in stroke patient?
It patient has electrolyte imbalance and hypothermia
Cerebral palsy; dx mri
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Verapamil

37. When to suspect traumatic LP
Myasthenia; due to autoantibodies against acetylecholine receptor;
RBC count >6000
Not within 24 hours; give afte 24-48 hours if patient stable
High dose IV methyleprednisone;

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

39. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Coronary artery disease
82% specific for dementia
Tunnel vision - diaphoresis - nausea - pallor

40. How to confirm braindeath?
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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.
Vitamin B12 deficiency
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

41. How to perform apnea test
Obturator n lesion
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
Taper gradually to prevent seizure relapse
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

42. 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Acetylecholinersterase inhibitors
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

43. What is pronator drift
RBC count >6000
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

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

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45. dementia plus urinary incontinence
Obturator n lesion
Lesion in nondominant temporal lobe
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

46. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Aphasia - neglect - agnosia - acalculia etc
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

47. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Myasthenia; due to autoantibodies against acetylecholine receptor;
High dose IV methyleprednisone;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Deficit in cranial nerve function

48. impaired perception of complex sounds
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebral palsy; dx mri
Construction apraxia; lesion in non dominant parietal lobe (right)
Lesion in nondominant temporal lobe

49. MMSE score of less than 24
82% specific for dementia
Nystagmus on far lateral gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acetylecholinersterase inhibitors

50. How to prevent prevent frequency of MS exacerbation
Corticosteroid and acyclovir
Despite the term neuroma they arise from schwann cells - schwanoma
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Antitoxin