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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. How to differentiate medial and lateral medullary syndrome
20%
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
Distal lower motor neuron disease

3. excessive elevation of legs during walking (toe touch floor earlier than heels)
90% of right handed and 60% of left handed persons; speech and language function
Distal lower motor neuron disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Obturator n lesion

4. labyrinthitis
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
Femoral n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting

5. MG
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Acetylecholinersterase inhibitors
Reduced efficacy of OCP
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

6. stroke with lower facial palsy - pronator drift despite on aspirin
Cerebellar lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Get up from chair walk a short distance turn around and sit; screening test for fall

7. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Spastic paraparesis

8. How to tx stroke patient came after 6h
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;
Aspirin - control HTN and swallow eval before giving any oral meds
Obturator n lesion

9. indication of plasmapheresis in GBS
90% of right handed and 60% of left handed persons; speech and language function
Acetylecholinersterase inhibitors
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Reduced efficacy of OCP

10. When to use dopamine agonist pramipexol in parkinson
Entacapone - COMT inhibitor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

11. What bp med to be given in a patient with high bp and signs of opioid withdrawal
82% specific for dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Clonidine will take care both high bp and withdrawal
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;

12. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Propranolol or primidone

13. GBS
Coronary artery disease
Diabetes insipidus
IVIG and plasmapheresis
Construction apraxia; lesion in non dominant parietal lobe (right)

14. cortical lesion
Taper gradually to prevent seizure relapse
Aphasia - neglect - agnosia - acalculia etc
Antitoxin
Distal lower motor neuron disease

15. Tx of GBS
Aspirin - control HTN and swallow eval before giving any oral meds
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

16. Tx of bells palsy
Corticosteroid and acyclovir
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

17. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Despite the term neuroma they arise from schwann cells - schwanoma
Spastic paraparesis
Entacapone - COMT inhibitor
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

18. oligoclonal band in CSF
Diabetes insipidus
MS
Aspirin - control HTN and swallow eval before giving any oral meds
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

19. brain stem lesion
Cerebral palsy; dx mri
Deficit in cranial nerve function
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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

20. phenytoin and OCP
Spastic paraparesis
Obturator n lesion
Reduced efficacy of OCP
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

21. Why V12 deficient develop hypokalemia after tx with b12
Spastic paraparesis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

22. differentiate wenicke and korsakoff
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
<20; if patient scores >25 benign forgetfulness
Verapamil
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

23. What is pronator drift
Difficulty in writing - calculating - distinguishing left and write
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Taper gradually to prevent seizure relapse

24. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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;
90% of right handed and 60% of left handed persons; speech and language function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

25. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
EPV - campylobacter - HSV
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Femoral n lesion

26. benign essential tremor
Normal pressure hydrocephalus
Propranolol or primidone
Corticosteroid and acyclovir
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

27. dementia plus urinary incontinence
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
Lesion in nondominant temporal lobe
Normal pressure hydrocephalus
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

28. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Spastic paraparesis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
90% of right handed and 60% of left handed persons; speech and language function

29. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
It patient has electrolyte imbalance and hypothermia
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
Spastic paraparesis

30. Acute onset of left arm weakness
Nystagmus on far lateral gaze
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
It patient has electrolyte imbalance and hypothermia

31. How to stop antiepileptic drugs
Distal lower motor neuron disease
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acetylecholinersterase inhibitors
Taper gradually to prevent seizure relapse

32. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Spastic paraparesis
Myasthenia; due to autoantibodies against acetylecholine receptor;

33. How to differentiate botulism from tick born paralysis - GBS and MG
20%
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Botulism has descending paralysis in contrast othere have ascending paralysis
It patient has electrolyte imbalance and hypothermia

34. MMSE score of less than 24
20%
82% specific for dementia
Vitamin B12 deficiency
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

35. impaired vibration and increased DTR
Taper gradually to prevent seizure relapse
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Vitamin B12 deficiency

36. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Despite the term neuroma they arise from schwann cells - schwanoma
Cerebellar lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

37. at first tingling in toes and feet then weakness in extremities
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
Normal pressure hydrocephalus
Construction apraxia; lesion in non dominant parietal lobe (right)
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

38. How to differentiate parkinson and benign essential tremor
Cerebellar lesion
<20; if patient scores >25 benign forgetfulness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

39. botulism
Antitoxin
Botulism has descending paralysis in contrast othere have ascending paralysis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

40. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Tunnel vision - diaphoresis - nausea - pallor
Femoral n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting

41. When to start fibrinolytic therapy in stroke patient?
Antitoxin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

42. lesion in dominant parietal lobe
Femoral n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Difficulty in writing - calculating - distinguishing left and write
High dose IV methyleprednisone;

43. anerior and anteriomedial thigh paresthesia - decreased DTR
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
Normal pressure hydrocephalus
Femoral n lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

44. get up and go test
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Get up from chair walk a short distance turn around and sit; screening test for fall

45. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir

46. How to tx lewy body dementia
Aphasia - neglect - agnosia - acalculia etc
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency
Autospy gold standard

47. How to confirm braindeath?
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
Cerebral palsy; dx mri
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.

48. severe headache and high BP
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
High dose IV methyleprednisone;

49. Blood transfusion in hypothermia
Difficulty in writing - calculating - distinguishing left and write
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Myasthenia; due to autoantibodies against acetylecholine receptor;

50. What mmse score suggest dementia
Femoral n lesion
Cerebral palsy; dx mri
<20; if patient scores >25 benign forgetfulness
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy