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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. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Cerebral palsy; dx mri
Obturator n lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Upright supine position

2. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Despite the term neuroma they arise from schwann cells - schwanoma
Tunnel vision - diaphoresis - nausea - pallor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

3. How to differentiate traumatic LP and SAH
Botulism has descending paralysis in contrast othere have ascending paralysis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

4. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

5. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Obturator n lesion
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

6. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
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

7. Patient with carbamazepine; What should be advice?
MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebral palsy; dx mri
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

8. Acute onset of left arm weakness
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

9. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cerebral palsy; dx mri

10. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Coronary artery disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

11. phenytoin and OCP
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
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
Reduced efficacy of OCP

12. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Despite the term neuroma they arise from schwann cells - schwanoma
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

13. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Botulism has descending paralysis in contrast othere have ascending paralysis
Clonidine will take care both high bp and withdrawal
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Lesion in nondominant temporal lobe

14. How to differentiate medial and lateral medullary syndrome
Cholinesterase inhibitor; and antiparkinsonism drugs
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;
Normal pressure hydrocephalus
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

15. severe headache and high BP
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
<20; if patient scores >25 benign forgetfulness
Propranolol or primidone

16. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
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
Femoral n lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

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

18. best diagnosis for parkinsonim
Distal lower motor neuron disease
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.
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Autospy gold standard

19. benign essential tremor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Propranolol or primidone
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

20. differentiate picks and huntington
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
Antitoxin
Obturator n lesion
Difficulty in writing - calculating - distinguishing left and write

21. double vision at the end of day and ptosis
Get up from chair walk a short distance turn around and sit; screening test for fall
Myasthenia; due to autoantibodies against acetylecholine receptor;
High dose IV methyleprednisone;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

22. Tx of bells palsy
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)
Corticosteroid and acyclovir
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

23. cluster headache
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
Distal lower motor neuron disease
Verapamil

24. How to differentiate parkinson and benign essential tremor
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
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
Nystagmus on far lateral gaze
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

25. acoustic neuroma
Cerebral palsy; dx mri
Despite the term neuroma they arise from schwann cells - schwanoma
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
EPV - campylobacter - HSV

26. lesion in dominant parietal lobe
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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

27. korsafoff psychosis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Gilberts disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

28. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Verapamil
Acetylecholinersterase inhibitors
EPV - campylobacter - HSV

29. earliest sign of phenytoin toxicity
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
Nystagmus on far lateral gaze
Gilberts disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

30. When to give aspirin when patient on tPA after stroke
Autospy gold standard
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Botulism has descending paralysis in contrast othere have ascending paralysis
Not within 24 hours; give afte 24-48 hours if patient stable

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

32. contraindication of sumatripta
Normal pressure hydrocephalus
RBC count >6000
Coronary artery disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

33. How to differentiate botulism from tick born paralysis - GBS and MG
82% specific for dementia
Spastic paraparesis
Coronary artery disease
Botulism has descending paralysis in contrast othere have ascending paralysis

34. impaired perception of complex sounds
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Lesion in nondominant temporal lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Obturator n lesion

35. what drug is used to extend effects of levodopa
Autospy gold standard
Entacapone - COMT inhibitor
Upright supine position
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

36. MG
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Acetylecholinersterase inhibitors
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

37. excessive elevation of legs during walking (toe touch floor earlier than heels)
Aphasia - neglect - agnosia - acalculia etc
Aspirin - control HTN and swallow eval before giving any oral meds
Distal lower motor neuron disease
Obturator n lesion

38. stroke with lower facial palsy - pronator drift despite on aspirin
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
Cerebral palsy; dx mri
Cerebellar lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

39. impaired hepatic conjugation of billirubin
Propranolol or primidone
90% of right handed and 60% of left handed persons; speech and language function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Gilberts disease

40. How to stop antiepileptic drugs
Femoral n 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
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse

41. When to suspect traumatic LP
Acetylecholinersterase inhibitors
It patient has electrolyte imbalance and hypothermia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
RBC count >6000

42. differentiate wenicke and korsakoff
82% specific for dementia
Taper gradually to prevent seizure relapse
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
Aphasia - neglect - agnosia - acalculia etc

43. How to prevent prevent frequency of MS exacerbation
IVIG and plasmapheresis
Obturator n lesion
Lesion in nondominant temporal lobe
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

44. How to confirm braindeath?
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Cerebral palsy; dx mri
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.
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

45. botulism
Antitoxin
Aspirin - control HTN and swallow eval before giving any oral meds
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

46. Should we tx htn in acute ischemic stroke

47. differentiate lewy body dementia and vascular dementia
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

48. oligoclonal band in CSF
MS
Reduced efficacy of OCP
IVIG and plasmapheresis
Obturator n lesion

49. dementia plus urinary incontinence
Normal pressure hydrocephalus
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

50. anerior and anteriomedial thigh paresthesia - decreased DTR
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Distal lower motor neuron disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Femoral n lesion