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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 give aspirin when patient on tPA after stroke
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Not within 24 hours; give afte 24-48 hours if patient stable
Distal lower motor neuron disease
MS

2. get up and go test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
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

3. Unable to copy of matchstick - unable to dress up
MS
Construction apraxia; lesion in non dominant parietal lobe (right)
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.
Follows viral illness; vertigo - tinnitus - nausea. self limiting

4. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Not within 24 hours; give afte 24-48 hours if patient stable
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
EPV - campylobacter - HSV

5. Tx of GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Nystagmus on far lateral gaze
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

6. best diagnosis for parkinsonim
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
EPV - campylobacter - HSV
Autospy gold standard

7. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in writing - calculating - distinguishing left and write

8. How to differentiate traumatic LP and SAH
Aphasia - neglect - agnosia - acalculia etc
Tunnel vision - diaphoresis - nausea - pallor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
82% specific for dementia

9. differentiate wenicke and korsakoff
It patient has electrolyte imbalance and hypothermia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Verapamil

10. impaired hepatic conjugation of billirubin
Gilberts disease
RBC count >6000
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

11. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
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
Get up from chair walk a short distance turn around and sit; screening test for fall

12. What is can be used cluster headache prevention
Cerebellar lesion
Verapamil
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position

13. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease
Reduced efficacy of OCP

14. Tx of bells palsy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
RBC count >6000
Corticosteroid and acyclovir
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

15. MMSE score of less than 24
Entacapone - COMT inhibitor
Difficulty in writing - calculating - distinguishing left and write
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia

16. Acute onset of left arm weakness
Autospy gold standard
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
90% of right handed and 60% of left handed persons; speech and language function

17. How to differentiate medial and lateral pontine syndrome
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

18. excessive elevation of legs during walking (toe touch floor earlier than heels)
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV
Distal lower motor neuron disease

19. differentiate picks and huntington
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Femoral n lesion
Deficit in cranial nerve function

20. 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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

21. When to use brain spect scintigraphy to confirm brain death
Entacapone - COMT inhibitor
It patient has electrolyte imbalance and hypothermia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Upright supine position

22. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Nystagmus on far lateral gaze
Spastic paraparesis
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.

23. benign essential tremor
Propranolol or primidone
Acetylecholinersterase inhibitors
Vitamin B12 deficiency
Entacapone - COMT inhibitor

24. prodrome of vasovagal syncope
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 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
Tunnel vision - diaphoresis - nausea - pallor
Aphasia - neglect - agnosia - acalculia etc

25. acoustic neuroma
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Despite the term neuroma they arise from schwann cells - schwanoma
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;

26. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
RBC count >6000
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Not within 24 hours; give afte 24-48 hours if patient stable

27. phenytoin and OCP
Reduced efficacy of OCP
Antitoxin
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
Cerebellar lesion

28. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs
Diabetes insipidus
Clonidine will take care both high bp and withdrawal

29. contraindication of sumatripta
Coronary artery disease
Despite the term neuroma they arise from schwann cells - schwanoma
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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

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

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31. What is pronator drift
Taper gradually to prevent seizure relapse
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
Gilberts disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

32. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Gilberts disease

33. How to differentiate parkinson and benign essential tremor
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
IVIG and plasmapheresis

34. dementia plus urinary incontinence
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Normal pressure hydrocephalus

35. medial thigh sensory loss and weakness in addcution
Corticosteroid and acyclovir
Obturator n lesion
Spastic paraparesis
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

36. How to prevent prevent frequency of MS exacerbation
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tunnel vision - diaphoresis - nausea - pallor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cerebral palsy; dx mri

37. How to confirm braindeath?
Diabetes insipidus
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.
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

38. cluster headache
Propranolol or primidone
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Lesion in nondominant temporal lobe

39. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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
Deficit in cranial nerve function

40. How to tx acute exacerbation of MS
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Get up from chair walk a short distance turn around and sit; screening test for fall
High dose IV methyleprednisone;
20%

41. oligoclonal band in CSF
Propranolol or primidone
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
82% specific for dementia
MS

42. stroke with lower facial palsy - pronator drift despite on aspirin
RBC count >6000
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Normal pressure hydrocephalus
IVIG and plasmapheresis

43. brain stem 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
Tunnel vision - diaphoresis - nausea - pallor
Deficit in cranial nerve function
Obturator n lesion

44. impaired vibration and increased DTR
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Acetylecholinersterase inhibitors

45. indication of plasmapheresis in GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
It patient has electrolyte imbalance and hypothermia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

46. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Femoral n lesion
Antitoxin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

47. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
82% specific for dementia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

48. impaired perception of complex sounds
Cerebellar lesion
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Lesion in nondominant temporal lobe

49. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
High dose IV methyleprednisone;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Propranolol or primidone

50. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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;
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;
Nystagmus on far lateral gaze