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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. excessive elevation of legs during walking (toe touch floor earlier than heels)
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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;
Distal lower motor neuron disease
Cerebral palsy; dx mri

2. benign essential tremor
Propranolol or primidone
Normal pressure hydrocephalus
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

3. craniopharyngioma
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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.
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Diabetes insipidus

4. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
High dose IV methyleprednisone;
Cerebellar lesion

5. cortical lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aphasia - neglect - agnosia - acalculia etc
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

6. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
IVIG and plasmapheresis
Myasthenia; due to autoantibodies against acetylecholine receptor;

7. When to suspect traumatic LP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MS
RBC count >6000
Corticosteroid and acyclovir

8. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
90% of right handed and 60% of left handed persons; speech and language function
Antitoxin
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;

9. phenytoin and OCP
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
High dose IV methyleprednisone;
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

10. anerior and anteriomedial thigh paresthesia - decreased DTR
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Femoral n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
90% of right handed and 60% of left handed persons; speech and language function

11. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Difficulty in writing - calculating - distinguishing left and write
Aspirin - control HTN and swallow eval before giving any oral meds

12. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Upright supine position
Construction apraxia; lesion in non dominant parietal lobe (right)

13. Patient with carbamazepine; What should be advice?
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;
Verapamil
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 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. get up and go test
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Get up from chair walk a short distance turn around and sit; screening test for fall

15. MG
Acetylecholinersterase inhibitors
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

16. How to perform apnea test
Get up from chair walk a short distance turn around and sit; screening test for fall
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Tunnel vision - diaphoresis - nausea - pallor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

17. How to tx lewy body dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Deficit in cranial nerve function
Cholinesterase inhibitor; and antiparkinsonism drugs
Entacapone - COMT inhibitor

18. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Despite the term neuroma they arise from schwann cells - schwanoma
EPV - campylobacter - HSV

19. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebellar lesion
Cerebral palsy; dx mri
Tunnel vision - diaphoresis - nausea - pallor

20. How to tx stroke patient came after 6h
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Taper gradually to prevent seizure relapse
Aspirin - control HTN and swallow eval before giving any oral meds
Aphasia - neglect - agnosia - acalculia etc

21. differentiate lewy body dementia and vascular dementia
Botulism has descending paralysis in contrast othere have ascending paralysis
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

22. 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.
Coronary artery disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

23. brain stem lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Femoral n lesion
Deficit in cranial nerve function

24. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MS
Upright supine position
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

25. korsafoff psychosis
Vitamin B12 deficiency
82% specific for dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

26. How to tx acute exacerbation of MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable
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
High dose IV methyleprednisone;

27. lesion in dominant parietal lobe
<20; if patient scores >25 benign forgetfulness
Difficulty in writing - calculating - distinguishing left and write
90% of right handed and 60% of left handed persons; speech and language function
Acetylecholinersterase inhibitors

28. What is can be used cluster headache prevention
Verapamil
Propranolol or primidone
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

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

30. oligoclonal band in CSF
MS
Corticosteroid and acyclovir
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Coronary artery disease

31. at first tingling in toes and feet then weakness in extremities
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Vitamin B12 deficiency
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

32. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
IVIG and plasmapheresis
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

33. When to use brain spect scintigraphy to confirm brain death
Tunnel vision - diaphoresis - nausea - pallor
It patient has electrolyte imbalance and hypothermia
Cholinesterase inhibitor; and antiparkinsonism 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

34. GBS
IVIG and plasmapheresis
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

35. Tx of GBS
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
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Taper gradually to prevent seizure relapse

36. prodrome of vasovagal syncope
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Normal pressure hydrocephalus
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

37. contraindication of sumatripta
82% specific for dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Coronary artery disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

38. What percent of dementia is reversible
It patient has electrolyte imbalance and hypothermia
Coronary artery disease
Reduced efficacy of OCP
20%

39. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Clonidine will take care both high bp and withdrawal

40. Should we tx htn in acute ischemic stroke

41. dominant parietal lobe on the left side
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
90% of right handed and 60% of left handed persons; speech and language function
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Construction apraxia; lesion in non dominant parietal lobe (right)

42. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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.
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Entacapone - COMT inhibitor

43. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Cerebellar lesion
Femoral n lesion
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

44. infections in GBS
Cerebellar lesion
EPV - campylobacter - HSV
20%
Botulism has descending paralysis in contrast othere have ascending paralysis

45. differentiate wenicke and korsakoff
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
Despite the term neuroma they arise from schwann cells - schwanoma
Deficit in cranial nerve function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

46. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
RBC count >6000
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

47. How to prevent prevent frequency of MS exacerbation
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

48. What mmse score suggest dementia
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
Not within 24 hours; give afte 24-48 hours if patient stable
<20; if patient scores >25 benign forgetfulness

49. How to confirm braindeath?
IVIG and plasmapheresis
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.
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

50. MMSE score of less than 24
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
82% specific for dementia
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
90% of right handed and 60% of left handed persons; speech and language function