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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. botulism
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Antitoxin
Entacapone - COMT inhibitor
Reduced efficacy of OCP

2. When to suspect traumatic LP
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
RBC count >6000
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

3. MMSE score of less than 24
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
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia

4. lesion in dominant parietal lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in writing - calculating - distinguishing left and write
Autospy gold standard
Cholinesterase inhibitor; and antiparkinsonism drugs

5. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
IVIG and plasmapheresis
Spastic paraparesis
Vitamin B12 deficiency

6. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
EPV - campylobacter - HSV

7. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Cerebral palsy; dx mri
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
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
Clonidine will take care both high bp and withdrawal

8. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
<20; if patient scores >25 benign forgetfulness
Corticosteroid and acyclovir
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

9. oligoclonal band in CSF
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

10. How to manage stroke patient came within 4 hours
Entacapone - COMT inhibitor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aspirin - control HTN and swallow eval before giving any oral meds

11. How to differentiate medial and lateral pontine syndrome
EPV - campylobacter - HSV
Autospy gold standard
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

12. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cholinesterase inhibitor; and antiparkinsonism drugs
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebral palsy; dx mri

13. 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
Cholinesterase inhibitor; and antiparkinsonism drugs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Propranolol or primidone

14. Blood transfusion in hypothermia
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

15. What mmse score suggest dementia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
<20; if patient scores >25 benign forgetfulness
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

16. benign essential tremor
Upright supine position
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Gilberts disease
Propranolol or primidone

17. women with unilateral eye pain; neurlogic symptoms here there at different times
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Diabetes insipidus
Gilberts disease

18. When to give aspirin when patient on tPA after stroke
Upright supine position
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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.
Not within 24 hours; give afte 24-48 hours if patient stable

19. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Gilberts 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
Autospy gold standard

20. craniopharyngioma
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
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard

21. earliest sign of phenytoin toxicity
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Nystagmus on far lateral gaze

22. contraindication of sumatripta
Coronary artery disease
Upright supine position
Clonidine will take care both high bp and withdrawal
Aspirin - control HTN and swallow eval before giving any oral meds

23. severe headache and high BP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

24. How to confirm braindeath?
Vitamin B12 deficiency
Not within 24 hours; give afte 24-48 hours if patient stable
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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.

25. impaired perception of complex sounds
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
Lesion in nondominant temporal lobe
Upright supine position
It patient has electrolyte imbalance and hypothermia

26. How to tx acute exacerbation of MS
Coronary artery disease
High dose IV methyleprednisone;
Get up from chair walk a short distance turn around and sit; screening test for fall
Myasthenia; due to autoantibodies against acetylecholine receptor;

27. impaired vibration and increased DTR
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
Vitamin B12 deficiency
Aphasia - neglect - agnosia - acalculia etc
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

28. differentiate wenicke and korsakoff
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
It patient has electrolyte imbalance and hypothermia
Acetylecholinersterase inhibitors

29. impaired hepatic conjugation of billirubin
Construction apraxia; lesion in non dominant parietal lobe (right)
Gilberts disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

30. How to differentiate parkinson and benign essential tremor
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.
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Spastic paraparesis
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

31. Tx of bells palsy
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
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
Corticosteroid and acyclovir
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

32. infections in GBS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal
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

33. What percent of dementia is reversible
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
20%
IVIG and plasmapheresis
Clonidine will take care both high bp and withdrawal

34. best diagnosis for parkinsonim
Construction apraxia; lesion in non dominant parietal lobe (right)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Autospy gold standard

35. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Aspirin - control HTN and swallow eval before giving any oral meds
Normal pressure hydrocephalus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Autospy gold standard

36. How to differentiate dementias
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Wernicke's encephalopathy; due to thiamine definition; medical emergency

37. double vision at the end of day and ptosis
MS
Myasthenia; due to autoantibodies against acetylecholine receptor;
Clonidine will take care both high bp and withdrawal
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

38. phenytoin and OCP
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.
90% of right handed and 60% of left handed persons; speech and language function
Reduced efficacy of OCP
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

39. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Botulism has descending paralysis in contrast othere have ascending paralysis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

40. acoustic neuroma
IVIG and plasmapheresis
Obturator n lesion
Despite the term neuroma they arise from schwann cells - schwanoma
Deficit in cranial nerve function

41. How to stop antiepileptic drugs
Coronary artery disease
RBC count >6000
Taper gradually to prevent seizure relapse
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

42. Tx of GBS
Cholinesterase inhibitor; and antiparkinsonism drugs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Corticosteroid and acyclovir

43. What is pronator drift
Obturator n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
RBC count >6000
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

44. lesion in dominant tempora lobe
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

45. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Botulism has descending paralysis in contrast othere have ascending paralysis
Gilberts disease
Deficit in cranial nerve function
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

46. How to perform apnea test
It patient has electrolyte imbalance and hypothermia
Construction apraxia; lesion in non dominant parietal lobe (right)
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

47. at first tingling in toes and feet then weakness in extremities
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
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

48. How to differentiate medial and lateral medullary syndrome
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;
Upright supine position
Nystagmus on far lateral gaze

49. brain stem lesion
Deficit in cranial nerve function
Femoral n lesion
20%
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

50. When to start fibrinolytic therapy in stroke patient?
Difficulty in writing - calculating - distinguishing left and write
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Propranolol or primidone
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA