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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. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
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
Cerebellar lesion

2. cortical lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Gilberts disease
RBC count >6000
Aphasia - neglect - agnosia - acalculia etc

3. women with unilateral eye pain; neurlogic symptoms here there at different times
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
IVIG and plasmapheresis
Upright supine position
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

4. get up and go test
Vitamin B12 deficiency
Get up from chair walk a short distance turn around and sit; screening test for fall
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

5. What percent of dementia is reversible
20%
Normal pressure hydrocephalus
Diabetes insipidus
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

6. What mmse score suggest dementia
Spastic paraparesis
82% specific for dementia
Not within 24 hours; give afte 24-48 hours if patient stable
<20; if patient scores >25 benign forgetfulness

7. 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
Despite the term neuroma they arise from schwann cells - schwanoma
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 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

8. When to give aspirin when patient on tPA after stroke
<20; if patient scores >25 benign forgetfulness
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Nystagmus on far lateral gaze
Not within 24 hours; give afte 24-48 hours if patient stable

9. How to differentiate medial and lateral pontine syndrome
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Corticosteroid and acyclovir
90% of right handed and 60% of left handed persons; speech and language function

10. Blood transfusion in hypothermia
Diabetes insipidus
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
<20; if patient scores >25 benign forgetfulness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

11. labyrinthitis
Diabetes insipidus
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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. korsafoff psychosis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Lesion in nondominant temporal lobe

13. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

14. GBS
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
IVIG and plasmapheresis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

15. 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
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.
RBC count >6000
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

16. oligoclonal band in CSF
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS
Normal pressure hydrocephalus
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.

17. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cholinesterase inhibitor; and antiparkinsonism drugs

18. Tx of bells palsy
Femoral n lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Corticosteroid and acyclovir

19. When to suspect traumatic LP
IVIG and plasmapheresis
RBC count >6000
Aspirin - control HTN and swallow eval before giving any oral meds
It patient has electrolyte imbalance and hypothermia

20. impaired vibration and increased DTR
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;
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;
Vitamin B12 deficiency

21. How to manage stroke patient came within 4 hours
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

22. differentiate wenicke and korsakoff
Acetylecholinersterase inhibitors
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
Difficulty in writing - calculating - distinguishing left and write
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

23. Acute onset of left arm weakness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Tunnel vision - diaphoresis - nausea - pallor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Vitamin B12 deficiency

24. differentiate picks and huntington
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Aspirin - control HTN and swallow eval before giving any oral meds

25. Unable to copy of matchstick - unable to dress up
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Antitoxin
Construction apraxia; lesion in non dominant parietal lobe (right)
IVIG and plasmapheresis

26. Tx of 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.
<20; if patient scores >25 benign forgetfulness
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

27. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
Vitamin B12 deficiency
High dose IV methyleprednisone;

28. 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
Get up from chair walk a short distance turn around and sit; screening test for fall
IVIG and plasmapheresis
Vitamin B12 deficiency

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

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30. at first tingling in toes and feet then weakness in extremities
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

31. acoustic neuroma
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Despite the term neuroma they arise from schwann cells - schwanoma
Lesion in nondominant temporal lobe
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

32. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
82% specific for dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting

33. MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors
Diabetes insipidus

34. How to differentiate medial and lateral medullary syndrome
Distal lower motor neuron disease
Acetylecholinersterase inhibitors
Gilberts disease
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;

35. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Nystagmus on far lateral gaze
Reduced efficacy of OCP

36. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Normal pressure hydrocephalus
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

37. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Clonidine will take care both high bp and withdrawal
Construction apraxia; lesion in non dominant parietal lobe (right)
Lesion in nondominant temporal lobe

38. 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
EPV - campylobacter - HSV
Entacapone - COMT inhibitor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

39. impaired perception of complex sounds
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MS
Lesion in nondominant temporal lobe
RBC count >6000

40. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Nystagmus on far lateral gaze
Cerebral palsy; dx mri
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

41. anerior and anteriomedial thigh paresthesia - decreased DTR
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
Difficulty in writing - calculating - distinguishing left and write
Normal pressure hydrocephalus
Femoral n lesion

42. When to start fibrinolytic therapy in stroke patient?
Despite the term neuroma they arise from schwann cells - schwanoma
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Botulism has descending paralysis in contrast othere have ascending paralysis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

43. dementia plus urinary incontinence
Cerebellar lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Normal pressure hydrocephalus
Distal lower motor neuron disease

44. differentiate lewy body dementia and vascular dementia
Antitoxin
Difficulty in writing - calculating - distinguishing left and write
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
Vitamin B12 deficiency

45. benign essential tremor
Verapamil
Propranolol or primidone
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

46. infections in GBS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

47. When to use dopamine agonist pramipexol in parkinson
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Obturator n lesion
Aphasia - neglect - agnosia - acalculia etc

48. What is can be used cluster headache prevention
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
It patient has electrolyte imbalance and hypothermia

49. phenytoin and OCP
Entacapone - COMT inhibitor
Cerebellar lesion
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

50. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Reduced efficacy of OCP
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Diabetes insipidus