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

2. indication of plasmapheresis in GBS
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease

3. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Propranolol or primidone
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

4. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
EPV - campylobacter - HSV
Lesion in nondominant temporal lobe
Cerebral palsy; dx mri
Despite the term neuroma they arise from schwann cells - schwanoma

5. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Nystagmus on far lateral gaze
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

6. impaired perception of complex sounds
EPV - campylobacter - HSV
Get up from chair walk a short distance turn around and sit; screening test for fall
Lesion in nondominant temporal lobe
90% of right handed and 60% of left handed persons; speech and language function

7. 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;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Deficit in cranial nerve function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

8. korsafoff psychosis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Reduced efficacy of OCP
Deficit in cranial nerve function
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

9. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spastic paraparesis
Botulism has descending paralysis in contrast othere have ascending paralysis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

10. oligoclonal band in CSF
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
90% of right handed and 60% of left handed persons; speech and language function
MS

11. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Cerebral palsy; dx mri
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

12. severe headache and high BP
Not within 24 hours; give afte 24-48 hours if patient stable
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
20%
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

13. cluster headache
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
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

14. When headache is presenting complaint of brain tumor
Propranolol or primidone
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Corticosteroid and acyclovir

15. labyrinthitis
Obturator n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Deficit in cranial nerve function
Taper gradually to prevent seizure relapse

16. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Upright supine position
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

17. When to give aspirin when patient on tPA after stroke
High dose IV methyleprednisone;
Not within 24 hours; give afte 24-48 hours if patient stable
Clonidine will take care both high bp and withdrawal
Lesion in nondominant temporal lobe

18. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus

19. contraindication of sumatripta
Coronary artery disease
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
82% specific for dementia
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;

20. best diagnosis for parkinsonim
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Autospy gold standard
Propranolol or primidone

21. Tx of bells palsy
Entacapone - COMT inhibitor
Corticosteroid and acyclovir
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

22. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Cerebral palsy; dx mri
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Deficit in cranial nerve function

23. what drug is used to extend effects of levodopa
Not within 24 hours; give afte 24-48 hours if patient stable
Entacapone - COMT inhibitor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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;

24. What mmse score suggest dementia
Despite the term neuroma they arise from schwann cells - schwanoma
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

25. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Deficit in cranial nerve function
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;
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

26. brain stem lesion
High dose IV methyleprednisone;
Spastic paraparesis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Deficit in cranial nerve function

27. differentiate picks and huntington
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

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

29. craniopharyngioma
Diabetes insipidus
High dose IV methyleprednisone;
Lesion in nondominant temporal lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

30. MMSE score of less than 24
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;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
82% specific for dementia

31. Patient with carbamazepine; What should be advice?
Vitamin B12 deficiency
20%
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

32. Blood transfusion in hypothermia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

33. How to stop antiepileptic drugs
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Taper gradually to prevent seizure relapse
Normal pressure hydrocephalus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

34. Why V12 deficient develop hypokalemia after tx with b12
Spastic paraparesis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Myasthenia; due to autoantibodies against acetylecholine receptor;

35. How to differentiate traumatic LP and SAH
Corticosteroid and acyclovir
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Distal lower motor neuron disease
It patient has electrolyte imbalance and hypothermia

36. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
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
Upright supine position
Clonidine will take care both high bp and withdrawal

37. What is pronator drift
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

38. get up and go test
Entacapone - COMT inhibitor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

39. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aphasia - neglect - agnosia - acalculia etc
20%
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

40. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Difficulty in writing - calculating - distinguishing left and write
Despite the term neuroma they arise from schwann cells - schwanoma
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

41. impaired vibration and increased DTR
RBC count >6000
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Vitamin B12 deficiency
Taper gradually to prevent seizure relapse

42. earliest sign of phenytoin toxicity
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Nystagmus on far lateral gaze
Acetylecholinersterase inhibitors
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

43. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
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.
Acetylecholinersterase inhibitors
Follows viral illness; vertigo - tinnitus - nausea. self limiting

44. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Upright supine position
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

45. phenytoin and OCP
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;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Reduced efficacy of OCP
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

46. When to suspect traumatic LP
Aphasia - neglect - agnosia - acalculia etc
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000
It patient has electrolyte imbalance and hypothermia

47. How to differentiate dementias
High dose IV methyleprednisone;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

48. Should we tx htn in acute ischemic stroke

49. medial thigh sensory loss and weakness in addcution
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Obturator n lesion
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

50. How to differentiate medial and lateral medullary syndrome
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;
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
MS
20%