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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. How to manage stroke patient came within 4 hours
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Cholinesterase inhibitor; and antiparkinsonism drugs

2. what drug is used to extend effects of levodopa
Cerebral palsy; dx mri
Lesion in nondominant temporal lobe
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

3. When to give aspirin when patient on tPA after stroke
Spastic paraparesis
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
20%
Not within 24 hours; give afte 24-48 hours if patient stable

4. benign essential tremor
Propranolol or primidone
IVIG and plasmapheresis
Nystagmus on far lateral gaze
Acetylecholinersterase inhibitors

5. How to differentiate parkinson and benign essential tremor
High dose IV methyleprednisone;
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
RBC count >6000

6. differentiate picks and huntington
Diabetes insipidus
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Autospy gold standard

7. When headache is presenting complaint of brain tumor
Upright supine position
Reduced efficacy of OCP
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

8. dominant parietal lobe on the left side
Coronary artery disease
IVIG and plasmapheresis
90% of right handed and 60% of left handed persons; speech and language function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

9. craniopharyngioma
Diabetes insipidus
Lesion in nondominant temporal lobe
Corticosteroid and acyclovir
Clonidine will take care both high bp and withdrawal

10. Why V12 deficient develop hypokalemia after tx with b12
Construction apraxia; lesion in non dominant parietal lobe (right)
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

11. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

12. double vision at the end of day and ptosis
Reduced efficacy of OCP
Myasthenia; due to autoantibodies against acetylecholine receptor;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Obturator n lesion

13. What is can be used cluster headache prevention
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
RBC count >6000

14. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Corticosteroid and acyclovir
IVIG and plasmapheresis
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

15. How to tx acute exacerbation of MS
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
20%
High dose IV methyleprednisone;
MS

16. earliest sign of phenytoin toxicity
Spastic paraparesis
Nystagmus on far lateral gaze
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebral palsy; dx mri

17. brain stem lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Vitamin B12 deficiency
Deficit in cranial nerve function

18. Tx of bells palsy
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Deficit in cranial nerve function
Corticosteroid and acyclovir

19. cortical lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Reduced efficacy of OCP
Aphasia - neglect - agnosia - acalculia etc

20. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Lesion in nondominant temporal lobe
Spastic paraparesis
Corticosteroid and acyclovir
Verapamil

21. What mmse score suggest dementia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Upright supine position
<20; if patient scores >25 benign forgetfulness
Follows viral illness; vertigo - tinnitus - nausea. self limiting

22. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Entacapone - COMT inhibitor
Lesion in nondominant temporal lobe

23. When to use brain spect scintigraphy to confirm brain death
Aphasia - neglect - agnosia - acalculia etc
Aspirin - control HTN and swallow eval before giving any oral meds
It patient has electrolyte imbalance and hypothermia
High dose IV methyleprednisone;

24. Tx of GBS
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
Cerebral palsy; dx mri
Entacapone - COMT inhibitor

25. How to confirm braindeath?
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
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.

26. impaired perception of complex sounds
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Lesion in nondominant temporal lobe
Taper gradually to prevent seizure relapse

27. phenytoin and OCP
82% specific for dementia
Reduced efficacy of OCP
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable

28. oligoclonal band in CSF
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS
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

29. Patient with carbamazepine; What should be advice?
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
EPV - campylobacter - HSV
<20; if patient scores >25 benign forgetfulness
Antitoxin

30. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Corticosteroid and acyclovir
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
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.

31. GBS
Femoral n lesion
IVIG and plasmapheresis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

32. Blood transfusion in hypothermia
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin

33. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Tunnel vision - diaphoresis - nausea - pallor

34. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
It patient has electrolyte imbalance and hypothermia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

35. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Get up from chair walk a short distance turn around and sit; screening test for fall
Clonidine will take care both high bp and withdrawal
Myasthenia; due to autoantibodies against acetylecholine receptor;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

36. 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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
It patient has electrolyte imbalance and hypothermia
IVIG and plasmapheresis

37. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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.
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Botulism has descending paralysis in contrast othere have ascending paralysis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

38. botulism
IVIG and plasmapheresis
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Antitoxin

39. How to prevent prevent frequency of MS exacerbation
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

40. Should we tx htn in acute ischemic stroke

41. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS
Difficulty in writing - calculating - distinguishing left and write
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

42. labyrinthitis
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Autospy gold standard
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

43. MG
Clonidine will take care both high bp and withdrawal
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acetylecholinersterase inhibitors
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;

44. Acute onset of left arm weakness
Difficulty in writing - calculating - distinguishing left and write
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Reduced efficacy of OCP
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

45. prodrome of vasovagal syncope
Clonidine will take care both high bp and withdrawal
Myasthenia; due to autoantibodies against acetylecholine receptor;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Tunnel vision - diaphoresis - nausea - pallor

46. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Entacapone - COMT inhibitor
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

47. infections in 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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
EPV - campylobacter - HSV
Nystagmus on far lateral gaze

48. How to differentiate medial and lateral medullary syndrome
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aspirin - control HTN and swallow eval before giving any oral meds
Spastic paraparesis
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;

49. How to differentiate traumatic LP and SAH
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Reduced efficacy of OCP
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

50. women with unilateral eye pain; neurlogic symptoms here there at different times
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
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS