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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. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Botulism has descending paralysis in contrast othere have ascending paralysis
Corticosteroid and acyclovir
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

2. what drug is used to extend effects of levodopa
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Entacapone - COMT inhibitor
<20; if patient scores >25 benign forgetfulness

3. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Vitamin B12 deficiency

4. best diagnosis for parkinsonim
Autospy gold standard
Cerebellar lesion
It patient has electrolyte imbalance and hypothermia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

5. What is pronator drift
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Get up from chair walk a short distance turn around and sit; screening test for fall
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

6. 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
Deficit in cranial nerve function
EPV - campylobacter - HSV
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

7. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Deficit in cranial nerve function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Nystagmus on far lateral gaze

8. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Acetylecholinersterase inhibitors
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

9. cortical lesion
Tunnel vision - diaphoresis - nausea - pallor
Diabetes insipidus
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc

10. Should we tx htn in acute ischemic stroke

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11. How to differentiate dementias
Despite the term neuroma they arise from schwann cells - schwanoma
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Clonidine will take care both high bp and withdrawal
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

12. infections in GBS
EPV - campylobacter - HSV
Botulism has descending paralysis in contrast othere have ascending paralysis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;

13. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
It patient has electrolyte imbalance and hypothermia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
20%

14. How to differentiate medial and lateral medullary syndrome
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

15. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
<20; if patient scores >25 benign forgetfulness

16. How to tx lewy body dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cholinesterase inhibitor; and antiparkinsonism drugs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

17. lesion in dominant tempora 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

18. Acute onset of left arm weakness
Botulism has descending paralysis in contrast othere have ascending paralysis
Nystagmus on far lateral gaze
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

19. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tunnel vision - diaphoresis - nausea - pallor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Propranolol or primidone

20. When to start fibrinolytic therapy in stroke patient?
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
Femoral n lesion
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

21. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Cholinesterase inhibitor; and antiparkinsonism drugs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Propranolol or primidone

22. Why V12 deficient develop hypokalemia after tx with b12
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Distal lower motor neuron disease
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

23. impaired perception of complex sounds
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
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
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

24. When to suspect traumatic LP
RBC count >6000
Gilberts disease
Spastic paraparesis
Diabetes insipidus

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

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26. stroke with lower facial palsy - pronator drift despite on aspirin
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
IVIG and plasmapheresis

27. When to use brain spect scintigraphy to confirm brain death
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
RBC count >6000
It patient has electrolyte imbalance and hypothermia
Cholinesterase inhibitor; and antiparkinsonism drugs

28. impaired vibration and increased DTR
90% of right handed and 60% of left handed persons; speech and language function
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS
Vitamin B12 deficiency

29. botulism
Antitoxin
Cerebellar lesion
IVIG and plasmapheresis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

30. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Reduced efficacy of OCP
Upright supine position
Normal pressure hydrocephalus

31. MMSE score of less than 24
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Botulism has descending paralysis in contrast othere have ascending paralysis
82% specific for dementia
Acetylecholinersterase inhibitors

32. prodrome of vasovagal syncope
90% of right handed and 60% of left handed persons; speech and language function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Tunnel vision - diaphoresis - nausea - pallor
Gilberts disease

33. Patient with carbamazepine; What should be advice?
Tunnel vision - diaphoresis - nausea - pallor
Antitoxin
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
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

34. craniopharyngioma
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Verapamil
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

35. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Autospy gold standard
Cerebellar lesion

36. How to prevent prevent frequency of MS exacerbation
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
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP

37. at first tingling in toes and feet then weakness in extremities
Taper gradually to prevent seizure relapse
Aphasia - neglect - agnosia - acalculia etc
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

38. When to give aspirin when patient on tPA after stroke
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Despite the term neuroma they arise from schwann cells - schwanoma
82% specific for dementia
Not within 24 hours; give afte 24-48 hours if patient stable

39. impaired hepatic conjugation of billirubin
Gilberts disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Construction apraxia; lesion in non dominant parietal lobe (right)

40. dementia plus urinary incontinence
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Normal pressure hydrocephalus
Aspirin - control HTN and swallow eval before giving any oral meds
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

41. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Corticosteroid and acyclovir
Reduced efficacy of OCP
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

42. phenytoin and OCP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Reduced efficacy of OCP
Propranolol or primidone
RBC count >6000

43. How to differentiate medial and lateral pontine syndrome
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
82% specific for dementia

44. 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
Taper gradually to prevent seizure relapse
82% specific for dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

45. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Despite the term neuroma they arise from schwann cells - schwanoma
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

46. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

47. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Entacapone - COMT inhibitor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebral palsy; dx mri

48. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma
Cerebral palsy; dx mri
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

49. When to use dopamine agonist pramipexol in parkinson
90% of right handed and 60% of left handed persons; speech and language function
Upright supine position
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

50. What percent of dementia is reversible
Difficulty in writing - calculating - distinguishing left and write
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Acetylecholinersterase inhibitors
20%