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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
It patient has electrolyte imbalance and hypothermia
<20; if patient scores >25 benign forgetfulness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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. craniopharyngioma
Diabetes insipidus
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Lesion in nondominant temporal lobe
Aspirin - control HTN and swallow eval before giving any oral meds

3. at first tingling in toes and feet then weakness in extremities
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Construction apraxia; lesion in non dominant parietal lobe (right)

4. 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
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.
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

5. botulism
Antitoxin
Autospy gold standard
Upright supine position
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

6. How to tx lewy body dementia
Despite the term neuroma they arise from schwann cells - schwanoma
Cholinesterase inhibitor; and antiparkinsonism drugs
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

7. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Propranolol or primidone

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

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9. Unable to copy of matchstick - unable to dress up
82% specific for dementia
Distal lower motor neuron disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

10. When to start fibrinolytic therapy in stroke patient?
Myasthenia; due to autoantibodies against acetylecholine receptor;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
82% specific for dementia
Not within 24 hours; give afte 24-48 hours if patient stable

11. Tx of GBS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Vitamin B12 deficiency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

12. impaired hepatic conjugation of billirubin
Gilberts disease
Nystagmus on far lateral gaze
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

13. contraindication of sumatripta
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Coronary artery disease

14. oligoclonal band in CSF
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
Deficit in cranial nerve function
Autospy gold standard

15. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Normal pressure hydrocephalus
Gilberts disease
EPV - campylobacter - HSV

16. When to use dopamine agonist pramipexol in parkinson
MS
Gilberts disease
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Wernicke's encephalopathy; due to thiamine definition; medical emergency

17. What mmse score suggest dementia
Upright supine position
<20; if patient scores >25 benign forgetfulness
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
High dose IV methyleprednisone;

18. How to stop antiepileptic drugs
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
Taper gradually to prevent seizure relapse
Upright supine position
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

19. How to differentiate traumatic LP and SAH
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Verapamil
20%

20. How to differentiate medial and lateral pontine syndrome
20%
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

21. medial thigh sensory loss and weakness in addcution
Antitoxin
Cerebral palsy; dx mri
Obturator n lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

22. How to differentiate dementias
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Botulism has descending paralysis in contrast othere have ascending paralysis
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

23. infections in GBS
Despite the term neuroma they arise from schwann cells - schwanoma
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
EPV - campylobacter - HSV
MS

24. differentiate lewy body dementia and vascular dementia
Obturator n lesion
Vitamin B12 deficiency
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
IVIG and plasmapheresis

25. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
EPV - campylobacter - HSV
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.
Upright supine position

26. excessive elevation of legs during walking (toe touch floor earlier than heels)
Cerebral palsy; dx mri
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Distal lower motor neuron disease

27. cluster headache
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Gilberts disease
Autospy gold standard
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

28. differentiate picks and huntington
Vitamin B12 deficiency
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Upright supine position

29. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

30. impaired vibration and increased DTR
Difficulty in writing - calculating - distinguishing left and write
Entacapone - COMT inhibitor
Autospy gold standard
Vitamin B12 deficiency

31. Acute onset of left arm weakness
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;
Aspirin - control HTN and swallow eval before giving any oral meds
IVIG and plasmapheresis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

32. impaired perception of complex sounds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Reduced efficacy of OCP
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe

33. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Lesion in nondominant temporal lobe
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

34. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
It patient has electrolyte imbalance and hypothermia
EPV - campylobacter - HSV

35. earliest sign of phenytoin toxicity
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
Nystagmus on far lateral gaze
Tunnel vision - diaphoresis - nausea - pallor

36. How to manage stroke patient came within 4 hours
Propranolol or primidone
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

37. lesion in dominant tempora lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Reduced efficacy of OCP
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

38. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
EPV - campylobacter - HSV

39. benign essential tremor
Propranolol or primidone
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cholinesterase inhibitor; and antiparkinsonism drugs

40. When headache is presenting complaint of brain tumor
It patient has electrolyte imbalance and hypothermia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Reduced efficacy of OCP
Not within 24 hours; give afte 24-48 hours if patient stable

41. Tx of bells palsy
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Corticosteroid and acyclovir
90% of right handed and 60% of left handed persons; speech and language function
Not within 24 hours; give afte 24-48 hours if patient stable

42. korsafoff psychosis
Cholinesterase inhibitor; and antiparkinsonism drugs
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
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

43. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Obturator n lesion
Vitamin B12 deficiency
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Myasthenia; due to autoantibodies against acetylecholine receptor;

44. What percent of dementia is reversible
20%
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
Reduced efficacy of OCP
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

45. dominant parietal lobe on the left side
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.
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

46. best diagnosis for parkinsonim
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Gilberts disease
Cerebral palsy; dx mri
Autospy gold standard

47. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

48. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
High dose IV methyleprednisone;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

49. How to differentiate botulism from tick born paralysis - GBS and MG
It patient has electrolyte imbalance and hypothermia
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tunnel vision - diaphoresis - nausea - pallor

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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Construction apraxia; lesion in non dominant parietal lobe (right)
Tunnel vision - diaphoresis - nausea - pallor