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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. When to give aspirin when patient on tPA after stroke
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Not within 24 hours; give afte 24-48 hours if patient stable
Aphasia - neglect - agnosia - acalculia etc

2. Patient with carbamazepine; What should be advice?
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Verapamil
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;

3. GBS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Aspirin - control HTN and swallow eval before giving any oral meds
IVIG and plasmapheresis
Deficit in cranial nerve function

4. How to confirm braindeath?
Aspirin - control HTN and swallow eval before giving any oral meds
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.
It patient has electrolyte imbalance and hypothermia
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

5. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Nystagmus on far lateral gaze
Spastic paraparesis
Corticosteroid and acyclovir
Taper gradually to prevent seizure relapse

6. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
20%
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

7. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

8. 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
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
Gilberts disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

9. How to prevent prevent frequency of MS exacerbation
Corticosteroid and acyclovir
Propranolol or primidone
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Follows viral illness; vertigo - tinnitus - nausea. self limiting

10. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Normal pressure hydrocephalus
Lesion in nondominant temporal lobe

11. phenytoin and OCP
Reduced efficacy of OCP
90% of right handed and 60% of left handed persons; speech and language function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus

12. differentiate picks and huntington
Vitamin B12 deficiency
Difficulty in writing - calculating - distinguishing left and write
Botulism has descending paralysis in contrast othere have ascending paralysis
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

13. How to differentiate botulism from tick born paralysis - GBS and MG
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
Taper gradually to prevent seizure relapse
Botulism has descending paralysis in contrast othere have ascending paralysis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

14. brain stem lesion
Femoral n lesion
Deficit in cranial nerve function
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acetylecholinersterase inhibitors

15. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Cerebellar lesion
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

16. what drug is used to extend effects of levodopa
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
Vitamin B12 deficiency
Entacapone - COMT inhibitor
Taper gradually to prevent seizure relapse

17. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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%
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

18. When headache is presenting complaint of brain tumor
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
Distal lower motor neuron disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

19. acoustic neuroma
Normal pressure hydrocephalus
Despite the term neuroma they arise from schwann cells - schwanoma
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

20. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

21. cortical lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Aphasia - neglect - agnosia - acalculia etc
Entacapone - COMT inhibitor
Construction apraxia; lesion in non dominant parietal lobe (right)

22. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Gilberts disease
Lesion in nondominant temporal lobe

23. Why V12 deficient develop hypokalemia after tx with b12
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

24. differentiate wenicke and korsakoff
Distal lower motor neuron disease
Reduced efficacy of OCP
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
Cerebral palsy; dx mri

25. Tx of GBS
Deficit in cranial nerve function
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Tunnel vision - diaphoresis - nausea - pallor
Cholinesterase inhibitor; and antiparkinsonism drugs

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

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27. How to differentiate parkinson and benign essential tremor
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
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

28. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

29. MMSE score of less than 24
82% specific for dementia
Clonidine will take care both high bp and withdrawal
Cerebral palsy; dx mri
IVIG and plasmapheresis

30. contraindication of sumatripta
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Coronary artery disease
IVIG and plasmapheresis

31. stroke with lower facial palsy - pronator drift despite on aspirin
82% specific for dementia
Lesion in nondominant temporal lobe
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.

32. oligoclonal band in CSF
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS
Botulism has descending paralysis in contrast othere have ascending paralysis

33. Tx of bells palsy
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Nystagmus on far lateral gaze
Corticosteroid and acyclovir
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

34. 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
Propranolol or primidone
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
Obturator n lesion

35. get up and go test
Propranolol or primidone
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

36. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Cerebellar lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

37. dementia plus urinary incontinence
Taper gradually to prevent seizure relapse
Distal lower motor neuron disease
Normal pressure hydrocephalus
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

38. anerior and anteriomedial thigh paresthesia - decreased DTR
20%
Femoral n lesion
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds

39. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

40. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Taper gradually to prevent seizure relapse
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
Not within 24 hours; give afte 24-48 hours if patient stable

41. How to differentiate medial and lateral pontine syndrome
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
Antitoxin
MS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

42. labyrinthitis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting

43. impaired perception of complex sounds
82% specific for dementia
Lesion in nondominant temporal lobe
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

44. lesion in dominant tempora lobe
Normal pressure hydrocephalus
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
Clonidine will take care both high bp and withdrawal

45. Blood transfusion in hypothermia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Propranolol or primidone

46. When to suspect traumatic LP
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
RBC count >6000
Reduced efficacy of OCP

47. impaired hepatic conjugation of billirubin
Gilberts disease
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
<20; if patient scores >25 benign forgetfulness
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

48. double vision at the end of day and ptosis
IVIG and plasmapheresis
Cerebellar lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Myasthenia; due to autoantibodies against acetylecholine receptor;

49. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Vitamin B12 deficiency
Construction apraxia; lesion in non dominant parietal lobe (right)
Botulism has descending paralysis in contrast othere have ascending paralysis

50. best diagnosis for parkinsonim
Reduced efficacy of OCP
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
High dose IV methyleprednisone;