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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 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
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
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. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tunnel vision - diaphoresis - nausea - pallor
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

3. How to differentiate medial and lateral medullary syndrome
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
Nystagmus on far lateral gaze
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;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

4. 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
Not within 24 hours; give afte 24-48 hours if patient stable
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.
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

5. contraindication of sumatripta
Coronary artery disease
Gilberts disease
MS
Distal lower motor neuron disease

6. differentiate picks and huntington
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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
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

7. brain stem lesion
Deficit in cranial nerve function
Difficulty in writing - calculating - distinguishing left and write
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.
RBC count >6000

8. Should we tx htn in acute ischemic stroke

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9. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Reduced efficacy of OCP
Cerebral palsy; dx mri
20%
RBC count >6000

10. earliest sign of phenytoin toxicity
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Gilberts disease

11. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
EPV - campylobacter - HSV

12. double vision at the end of day and ptosis
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in writing - calculating - distinguishing left and write
Myasthenia; due to autoantibodies against acetylecholine receptor;
Entacapone - COMT inhibitor

13. prodrome of vasovagal syncope
Entacapone - COMT inhibitor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tunnel vision - diaphoresis - nausea - pallor
Coronary artery disease

14. dementia plus urinary incontinence
Aspirin - control HTN and swallow eval before giving any oral meds
Normal pressure hydrocephalus
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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;

15. benign essential tremor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Propranolol or primidone
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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

16. labyrinthitis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

17. How to stop antiepileptic drugs
90% of right handed and 60% of left handed persons; speech and language function
Normal pressure hydrocephalus
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

18. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
<20; if patient scores >25 benign forgetfulness

19. impaired vibration and increased DTR
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Vitamin B12 deficiency
Despite the term neuroma they arise from schwann cells - schwanoma

20. impaired hepatic conjugation of billirubin
Gilberts disease
Verapamil
Tunnel vision - diaphoresis - nausea - pallor
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

21. When to start fibrinolytic therapy in stroke patient?
Obturator n lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Taper gradually to prevent seizure relapse
Distal lower motor neuron disease

22. When to suspect traumatic LP
Distal lower motor neuron disease
Propranolol or primidone
RBC count >6000
Spastic paraparesis

23. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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.
Aphasia - neglect - agnosia - acalculia etc
Upright supine position

24. What percent of dementia is reversible
20%
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

25. severe headache and high BP
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
Cerebellar lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

26. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Get up from chair walk a short distance turn around and sit; screening test for fall
Spastic paraparesis
<20; if patient scores >25 benign forgetfulness
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

27. How to confirm braindeath?
Get up from chair walk a short distance turn around and sit; screening test for fall
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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.
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

28. Blood transfusion in hypothermia
RBC count >6000
MS
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

29. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Clonidine will take care both high bp and withdrawal
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

30. How to tx stroke patient came after 6h
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aspirin - control HTN and swallow eval before giving any oral meds
Normal pressure hydrocephalus

31. How to perform 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Gilberts disease

32. How to tx lewy body dementia
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Cholinesterase inhibitor; and antiparkinsonism drugs

33. How to tx acute exacerbation of MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
High dose IV methyleprednisone;

34. women with unilateral eye pain; neurlogic symptoms here there at different times
MS
Acetylecholinersterase inhibitors
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Clonidine will take care both high bp and withdrawal

35. medial thigh sensory loss and weakness in addcution
Lesion in nondominant temporal lobe
Obturator n lesion
RBC count >6000
Cerebellar lesion

36. Acute onset of left arm weakness
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Gilberts disease
Construction apraxia; lesion in non dominant parietal lobe (right)

37. How to differentiate traumatic LP and SAH
Propranolol or primidone
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Deficit in cranial nerve function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

38. When to use dopamine agonist pramipexol in parkinson
Deficit in cranial nerve function
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
RBC count >6000
Difficulty in writing - calculating - distinguishing left and write

39. get up and go test
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
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.

40. MMSE score of less than 24
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Not within 24 hours; give afte 24-48 hours if patient stable
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
82% specific for dementia

41. Unable to copy of matchstick - unable to dress up
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Distal lower motor neuron disease
Spastic paraparesis

42. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

43. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Autospy gold standard
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

44. oligoclonal band in CSF
MS
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
High dose IV methyleprednisone;

45. Why V12 deficient develop hypokalemia after tx with b12
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spastic paraparesis
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

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

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47. Tx of bells palsy
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Upright supine position
Corticosteroid and acyclovir
Coronary artery disease

48. How to differentiate medial and lateral pontine syndrome
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
Antitoxin
Cerebellar lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

49. phenytoin and OCP
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Reduced efficacy of OCP

50. indication of plasmapheresis in GBS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Verapamil
Construction apraxia; lesion in non dominant parietal lobe (right)
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure