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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. dementia plus urinary incontinence
Difficulty in writing - calculating - distinguishing left and write
Normal pressure hydrocephalus
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

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

3. stroke with lower facial palsy - pronator drift despite on aspirin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Cerebral palsy; dx mri
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Propranolol or primidone

4. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Reduced efficacy of OCP
Clonidine will take care both high bp and withdrawal
Taper gradually to prevent seizure relapse

5. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

6. 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
Obturator n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

7. anerior and anteriomedial thigh paresthesia - decreased DTR
MS
EPV - campylobacter - HSV
Femoral n lesion
Autospy gold standard

8. What percent of dementia is reversible
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Tunnel vision - diaphoresis - nausea - pallor
Cholinesterase inhibitor; and antiparkinsonism drugs
20%

9. MG
Coronary artery disease
Acetylecholinersterase inhibitors
Gilberts disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

10. impaired hepatic conjugation of billirubin
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Gilberts disease
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

11. Should we tx htn in acute ischemic stroke

12. How to differentiate botulism from tick born paralysis - GBS and MG
Femoral n lesion
Botulism has descending paralysis in contrast othere have ascending paralysis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

13. brain stem lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Deficit in cranial nerve function
<20; if patient scores >25 benign forgetfulness
Cholinesterase inhibitor; and antiparkinsonism drugs

14. labyrinthitis
Despite the term neuroma they arise from schwann cells - schwanoma
Entacapone - COMT inhibitor
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

15. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Antitoxin
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cholinesterase inhibitor; and antiparkinsonism drugs

16. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Verapamil
Antitoxin
Propranolol or primidone

17. 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
Spastic paraparesis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tunnel vision - diaphoresis - nausea - pallor

18. prodrome of vasovagal syncope
Verapamil
Construction apraxia; lesion in non dominant parietal lobe (right)
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;

19. impaired perception of complex sounds
It patient has electrolyte imbalance and hypothermia
Obturator n lesion
Cerebellar lesion
Lesion in nondominant temporal lobe

20. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease
90% of right handed and 60% of left handed persons; speech and language function

21. MMSE score of less than 24
82% specific for dementia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Cerebral palsy; dx mri
Femoral n lesion

22. Unable to copy of matchstick - unable to dress up
Myasthenia; due to autoantibodies against acetylecholine receptor;
Botulism has descending paralysis in contrast othere have ascending paralysis
Construction apraxia; lesion in non dominant parietal lobe (right)
Taper gradually to prevent seizure relapse

23. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Botulism has descending paralysis in contrast othere have ascending paralysis
Corticosteroid and acyclovir
Entacapone - COMT inhibitor

24. what drug is used to extend effects of levodopa
Obturator n lesion
Entacapone - COMT inhibitor
Spastic paraparesis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

25. What is pronator drift
Coronary artery disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
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;

26. Tx of GBS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Nystagmus on far lateral gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

27. When to suspect traumatic LP
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Acetylecholinersterase inhibitors
EPV - campylobacter - HSV
RBC count >6000

28. Patient with carbamazepine; What should be advice?
Cerebral palsy; dx mri
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

29. How to manage stroke patient came within 4 hours
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
RBC count >6000

30. Tx of bells palsy
Corticosteroid and acyclovir
Cerebral palsy; dx mri
Propranolol or primidone
Not within 24 hours; give afte 24-48 hours if patient stable

31. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

32. Acute onset of left arm weakness
Spastic paraparesis
Antitoxin
Cerebral palsy; dx mri
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

33. GBS
IVIG and plasmapheresis
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
Autospy gold standard

34. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebellar lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Not within 24 hours; give afte 24-48 hours if patient stable

35. How to tx lewy body dementia
Vitamin B12 deficiency
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spastic paraparesis
Cholinesterase inhibitor; and antiparkinsonism drugs

36. double vision at the end of day and ptosis
Upright supine position
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

37. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

38. indication of plasmapheresis in GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion

39. infections in GBS
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
EPV - campylobacter - HSV

40. How to confirm braindeath?
Antitoxin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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.

41. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Cerebellar lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;

42. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Upright supine position
90% of right handed and 60% of left handed persons; speech and language function
Despite the term neuroma they arise from schwann cells - schwanoma

43. korsafoff psychosis
Coronary artery disease
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
Get up from chair walk a short distance turn around and sit; screening test for fall

44. 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
Construction apraxia; lesion in non dominant parietal lobe (right)
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

45. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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
Coronary artery disease
Clonidine will take care both high bp and withdrawal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

46. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
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
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

47. phenytoin and OCP
Cerebral palsy; dx mri
Reduced efficacy of OCP
Verapamil
Entacapone - COMT inhibitor

48. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Coronary artery disease
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
Taper gradually to prevent seizure relapse
Spastic paraparesis

49. How to stop antiepileptic drugs
Obturator n lesion
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
Taper gradually to prevent seizure relapse

50. What is can be used cluster headache prevention
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Verapamil
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
90% of right handed and 60% of left handed persons; speech and language function