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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. earliest sign of phenytoin toxicity
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in writing - calculating - distinguishing left and write

2. 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
Nystagmus on far lateral gaze
Get up from chair walk a short distance turn around and sit; screening test for fall
Reduced efficacy of OCP

3. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
82% specific for dementia
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

4. What mmse score suggest dementia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Diabetes insipidus
<20; if patient scores >25 benign forgetfulness
Corticosteroid and acyclovir

5. brain stem lesion
Propranolol or primidone
Deficit in cranial nerve function
Get up from chair walk a short distance turn around and sit; screening test for fall
MS

6. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Upright supine position
Cerebral palsy; dx mri

7. How to manage stroke patient came within 4 hours
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

8. acoustic neuroma
Autospy gold standard
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Despite the term neuroma they arise from schwann cells - schwanoma
It patient has electrolyte imbalance and hypothermia

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

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10. How to perform apnea test
Clonidine will take care both high bp and withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

11. When to start fibrinolytic therapy in stroke patient?
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

12. MG
Aphasia - neglect - agnosia - acalculia etc
Lesion in nondominant temporal lobe
Acetylecholinersterase inhibitors
Despite the term neuroma they arise from schwann cells - schwanoma

13. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Corticosteroid and acyclovir

14. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
RBC count >6000
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

15. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
It patient has electrolyte imbalance and hypothermia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse

16. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
High dose IV methyleprednisone;
Difficulty in writing - calculating - distinguishing left and write
Spastic paraparesis

17. How to tx lewy body dementia
<20; if patient scores >25 benign forgetfulness
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Upright supine position
Cholinesterase inhibitor; and antiparkinsonism drugs

18. How to prevent prevent frequency of MS exacerbation
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

19. What percent of dementia is reversible
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
RBC count >6000
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.

20. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Propranolol or primidone
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

21. How to differentiate traumatic LP and SAH
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Aspirin - control HTN and swallow eval before giving any oral meds
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

22. lesion in dominant parietal lobe
Tunnel vision - diaphoresis - nausea - pallor
Difficulty in writing - calculating - distinguishing left and write
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
EPV - campylobacter - HSV

23. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Myasthenia; due to autoantibodies against acetylecholine receptor;
Entacapone - COMT inhibitor
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
Spastic paraparesis

24. korsafoff psychosis
<20; if patient scores >25 benign forgetfulness
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard

25. How to confirm braindeath?
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.
Spastic paraparesis
Femoral n lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

26. infections in GBS
EPV - campylobacter - HSV
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebellar lesion
90% of right handed and 60% of left handed persons; speech and language function

27. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
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
Tunnel vision - diaphoresis - nausea - pallor

28. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
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

29. When to suspect traumatic LP
Reduced efficacy of OCP
RBC count >6000
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
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

30. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

31. 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
High dose IV methyleprednisone;
RBC count >6000
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

32. Patient with carbamazepine; What should be advice?
Clonidine will take care both high bp and withdrawal
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Autospy gold standard

33. indication of plasmapheresis in GBS
Antitoxin
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

34. medial thigh sensory loss and weakness in addcution
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion
Deficit in cranial nerve function
Myasthenia; due to autoantibodies against acetylecholine receptor;

35. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
<20; if patient scores >25 benign forgetfulness
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

36. lesion in dominant tempora lobe
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
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

37. craniopharyngioma
Diabetes insipidus
<20; if patient scores >25 benign forgetfulness
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

38. dominant parietal lobe on the left side
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
RBC count >6000
Vitamin B12 deficiency
90% of right handed and 60% of left handed persons; speech and language function

39. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Botulism has descending paralysis in contrast othere have ascending paralysis
Gilberts disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

40. cluster headache
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
<20; if patient scores >25 benign forgetfulness
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Despite the term neuroma they arise from schwann cells - schwanoma

41. get up and go test
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aphasia - neglect - agnosia - acalculia etc
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
Get up from chair walk a short distance turn around and sit; screening test for fall

42. impaired hepatic conjugation of billirubin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Gilberts disease
Coronary artery disease

43. MMSE score of less than 24
Obturator n lesion
82% specific for dementia
Despite the term neuroma they arise from schwann cells - schwanoma
Normal pressure hydrocephalus

44. differentiate picks and huntington
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;
RBC count >6000
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

45. benign essential tremor
EPV - campylobacter - HSV
Cerebellar lesion
Propranolol or primidone
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

46. GBS
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
Nystagmus on far lateral gaze
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
IVIG and plasmapheresis

47. botulism
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
RBC count >6000
Antitoxin

48. differentiate lewy body dementia and vascular dementia
Despite the term neuroma they arise from schwann cells - schwanoma
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
Normal pressure hydrocephalus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

49. impaired vibration and increased DTR
Cerebral palsy; dx mri
Vitamin B12 deficiency
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency

50. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
20%
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH