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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. cortical lesion
Femoral n lesion
Aphasia - neglect - agnosia - acalculia etc
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
Botulism has descending paralysis in contrast othere have ascending paralysis

2. How to differentiate medial and lateral medullary syndrome
Botulism has descending paralysis in contrast othere have ascending paralysis
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;
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

3. korsafoff psychosis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

4. excessive elevation of legs during walking (toe touch floor earlier than heels)
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Distal lower motor neuron disease
Reduced efficacy of OCP

5. How to stop antiepileptic drugs
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
Taper gradually to prevent seizure relapse
Propranolol or primidone

6. How to differentiate medial and lateral pontine syndrome
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

7. at first tingling in toes and feet then weakness in extremities
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
It patient has electrolyte imbalance and hypothermia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

9. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Verapamil
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
It patient has electrolyte imbalance and hypothermia

10. prodrome of vasovagal syncope
MS
Tunnel vision - diaphoresis - nausea - pallor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

11. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Follows viral illness; vertigo - tinnitus - nausea. self limiting
<20; if patient scores >25 benign forgetfulness

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

13. women with unilateral eye pain; neurlogic symptoms here there at different times
MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

14. How to manage stroke patient came within 4 hours
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

15. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

16. botulism
Nystagmus on far lateral gaze
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

17. indication of plasmapheresis in GBS
20%
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

18. How to tx acute exacerbation of MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

19. cluster headache
Tunnel vision - diaphoresis - nausea - pallor
IVIG and plasmapheresis
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

20. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Upright supine position
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

21. How to differentiate dementias
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Acetylecholinersterase inhibitors
Distal lower motor neuron disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

22. MG
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe
Aphasia - neglect - agnosia - acalculia etc
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

23. phenytoin and OCP
Upright supine position
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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

24. lesion in dominant parietal lobe
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Distal lower motor neuron disease

25. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Aphasia - neglect - agnosia - acalculia etc
High dose IV methyleprednisone;
Propranolol or primidone

26. contraindication of sumatripta
Despite the term neuroma they arise from schwann cells - schwanoma
Spastic paraparesis
Coronary artery disease
Not within 24 hours; give afte 24-48 hours if patient stable

27. What is pronator drift
82% specific for dementia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
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

28. differentiate picks and huntington
It patient has electrolyte imbalance and hypothermia
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
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
Normal pressure hydrocephalus

29. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Nystagmus on far lateral gaze
Entacapone - COMT inhibitor

30. double vision at the end of day and ptosis
IVIG and plasmapheresis
Clonidine will take care both high bp and withdrawal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;

31. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

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
MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

33. impaired hepatic conjugation of billirubin
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in writing - calculating - distinguishing left and write
Gilberts disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

34. impaired perception of complex sounds
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe
Deficit in cranial nerve function
It patient has electrolyte imbalance and hypothermia

35. impaired vibration and increased DTR
Taper gradually to prevent seizure relapse
Botulism has descending paralysis in contrast othere have ascending paralysis
Vitamin B12 deficiency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

36. When headache is presenting complaint of brain tumor
Acetylecholinersterase inhibitors
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

37. How to prevent prevent frequency of MS exacerbation
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
IVIG and plasmapheresis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

38. labyrinthitis
Deficit in cranial nerve function
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Antitoxin

39. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS

40. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Deficit in cranial nerve function
Cerebral palsy; dx mri
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
<20; if patient scores >25 benign forgetfulness

41. Tx of GBS
82% specific for dementia
MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
20%

42. How to differentiate parkinson and benign essential tremor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Vitamin B12 deficiency
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

43. stroke with lower facial palsy - pronator drift despite on aspirin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
82% specific for dementia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

44. What percent of dementia is reversible
20%
Gilberts disease
Entacapone - COMT inhibitor
Despite the term neuroma they arise from schwann cells - schwanoma

45. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Gilberts disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

46. dementia plus urinary incontinence
Myasthenia; due to autoantibodies against acetylecholine receptor;
Normal pressure hydrocephalus
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

47. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
<20; if patient scores >25 benign forgetfulness
Diabetes insipidus
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

48. get up and go test
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Coronary artery disease
Get up from chair walk a short distance turn around and sit; screening test for fall

49. Patient with carbamazepine; What should be advice?
Deficit in cranial nerve function
Difficulty in writing - calculating - distinguishing left and write
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

50. differentiate wenicke and korsakoff
Clonidine will take care both high bp and withdrawal
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised