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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. phenytoin and OCP
Entacapone - COMT inhibitor
Reduced efficacy of OCP
Corticosteroid and acyclovir
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

2. cortical lesion
Femoral n lesion
82% specific for dementia
Aphasia - neglect - agnosia - acalculia etc
Acetylecholinersterase inhibitors

3. 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
Femoral n lesion
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

4. impaired perception of complex sounds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
Acetylecholinersterase inhibitors

5. oligoclonal band in CSF
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Distal lower motor neuron disease

6. anerior and anteriomedial thigh paresthesia - decreased DTR
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Femoral n lesion
Upright supine position
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

7. brain stem lesion
Deficit in cranial nerve function
Nystagmus on far lateral gaze
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

8. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Construction apraxia; lesion in non dominant parietal lobe (right)
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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

9. Blood transfusion in hypothermia
Antitoxin
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

10. When to use brain spect scintigraphy to confirm brain death
Femoral n lesion
It patient has electrolyte imbalance and hypothermia
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Lesion in nondominant temporal lobe

11. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Upright supine position
Clonidine will take care both high bp and withdrawal
<20; if patient scores >25 benign forgetfulness

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

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

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14. How to differentiate dementias
Diabetes insipidus
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Cerebellar lesion

15. botulism
Antitoxin
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
It patient has electrolyte imbalance and hypothermia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

16. contraindication of sumatripta
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
Coronary artery disease
Not within 24 hours; give afte 24-48 hours if patient stable
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

17. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

18. What is pronator drift
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
20%

19. When to start fibrinolytic therapy in stroke patient?
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
RBC count >6000
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

20. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebellar lesion
Aspirin - control HTN and swallow eval before giving any oral meds
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

21. infections in GBS
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.
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc
RBC count >6000

22. best diagnosis for parkinsonim
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Autospy gold standard
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Botulism has descending paralysis in contrast othere have ascending paralysis

23. differentiate lewy body dementia and vascular dementia
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
RBC count >6000
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

24. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Gilberts disease
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

25. How to differentiate parkinson and benign essential tremor
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

26. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Difficulty in writing - calculating - distinguishing left and write
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Nystagmus on far lateral gaze

27. 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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in writing - calculating - distinguishing left and write
It patient has electrolyte imbalance and hypothermia

28. 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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
High dose IV methyleprednisone;

29. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Autospy gold standard
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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;

30. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
IVIG and plasmapheresis

31. medial thigh sensory loss and weakness in addcution
Botulism has descending paralysis in contrast othere have ascending paralysis
Obturator n lesion
Autospy gold standard
Spastic paraparesis

32. differentiate wenicke and korsakoff
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;
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

33. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Taper gradually to prevent seizure relapse
Clonidine will take care both high bp and withdrawal
Get up from chair walk a short distance turn around and sit; screening test for fall
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

34. MG
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
High dose IV methyleprednisone;
Acetylecholinersterase inhibitors
Not within 24 hours; give afte 24-48 hours if patient stable

35. dominant parietal lobe on the left side
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Gilberts disease
90% of right handed and 60% of left handed persons; speech and language function
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

36. stroke with lower facial palsy - pronator drift despite on aspirin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

37. Acute onset of left arm weakness
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Botulism has descending paralysis in contrast othere have ascending paralysis

38. differentiate picks and huntington
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
Entacapone - COMT inhibitor
Distal lower motor neuron 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

39. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
MS
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
Cerebellar lesion

40. at first tingling in toes and feet then weakness in extremities
Taper gradually to prevent seizure relapse
82% specific for dementia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

41. korsafoff psychosis
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Get up from chair walk a short distance turn around and sit; screening test for fall

42. Unable to copy of matchstick - unable to dress up
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Not within 24 hours; give afte 24-48 hours if patient stable
Spastic paraparesis

43. What percent of dementia is reversible
20%
Verapamil
RBC count >6000
82% specific for dementia

44. How to differentiate medial and lateral pontine syndrome
Taper gradually to prevent seizure relapse
Corticosteroid and acyclovir
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

45. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Tunnel vision - diaphoresis - nausea - pallor
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
Spastic paraparesis

46. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Entacapone - COMT inhibitor
Aphasia - neglect - agnosia - acalculia etc
Nystagmus on far lateral gaze

47. benign essential tremor
Coronary artery disease
Tunnel vision - diaphoresis - nausea - pallor
Distal lower motor neuron disease
Propranolol or primidone

48. dementia plus urinary incontinence
Normal pressure hydrocephalus
Deficit in cranial nerve function
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
90% of right handed and 60% of left handed persons; speech and language function

49. severe headache and high BP
Tunnel vision - diaphoresis - nausea - pallor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Construction apraxia; lesion in non dominant parietal lobe (right)
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

50. When headache is presenting complaint of brain tumor
RBC count >6000
Coronary artery disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening