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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. oligoclonal band in CSF
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

2. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
90% of right handed and 60% of left handed persons; speech and language function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Botulism has descending paralysis in contrast othere have ascending paralysis

3. get up and go test
90% of right handed and 60% of left handed persons; speech and language function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Get up from chair walk a short distance turn around and sit; screening test for fall
Lesion in nondominant temporal lobe

4. 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
Autospy gold standard
Not within 24 hours; give afte 24-48 hours if patient stable
Spastic paraparesis

5. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Cerebellar lesion

6. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Gilberts 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
Difficulty in writing - calculating - distinguishing left and write

7. When to use dopamine agonist pramipexol in parkinson
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
Corticosteroid and acyclovir
Get up from chair walk a short distance turn around and sit; screening test for fall

8. Acute onset of left arm weakness
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

9. dominant parietal lobe on the left side
Taper gradually to prevent seizure relapse
Tunnel vision - diaphoresis - nausea - pallor
Upright supine position
90% of right handed and 60% of left handed persons; speech and language function

10. MG
Taper gradually to prevent seizure relapse
Entacapone - COMT inhibitor
Acetylecholinersterase inhibitors
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

11. lesion in dominant tempora lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Upright supine position
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;

12. Should we tx htn in acute ischemic stroke

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13. How to tx acute exacerbation of MS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
High dose IV methyleprednisone;
Vitamin B12 deficiency

14. 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
Cholinesterase inhibitor; and antiparkinsonism drugs
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

15. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Vitamin B12 deficiency
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

16. Tx of bells palsy
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin
Corticosteroid and acyclovir

17. 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
Lesion in nondominant temporal lobe
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

18. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Taper gradually to prevent seizure relapse
Deficit in cranial nerve function
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

19. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Upright supine position

20. 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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
It patient has electrolyte imbalance and hypothermia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

21. 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;
82% specific for dementia
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

22. dementia plus urinary incontinence
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

23. differentiate wenicke and korsakoff
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

24. differentiate picks and huntington
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

25. GBS
IVIG and plasmapheresis
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
Coronary artery disease

26. What is can be used cluster headache prevention
Verapamil
Gilberts disease
Upright supine position
EPV - campylobacter - HSV

27. 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;
Vitamin B12 deficiency
Autospy gold standard
<20; if patient scores >25 benign forgetfulness

28. brain stem lesion
Deficit in cranial nerve function
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aphasia - neglect - agnosia - acalculia etc
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

29. labyrinthitis
Propranolol or primidone
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Follows viral illness; vertigo - tinnitus - nausea. self limiting

30. what drug is used to extend effects of levodopa
RBC count >6000
Entacapone - COMT inhibitor
Vitamin B12 deficiency
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

31. When to suspect traumatic LP
Get up from chair walk a short distance turn around and sit; screening test for fall
Distal lower motor neuron disease
RBC count >6000
Follows viral illness; vertigo - tinnitus - nausea. self limiting

32. How to confirm braindeath?
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
Lesion in nondominant temporal lobe
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.

33. How to differentiate medial and lateral pontine syndrome
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

34. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Normal pressure hydrocephalus
Autospy gold standard
Cerebral palsy; dx mri

35. craniopharyngioma
Diabetes insipidus
Reduced efficacy of OCP
IVIG and plasmapheresis
Not within 24 hours; give afte 24-48 hours if patient stable

36. infections in GBS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebral palsy; dx mri
EPV - campylobacter - HSV
Taper gradually to prevent seizure relapse

37. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Obturator n lesion
Verapamil
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

38. How to tx lewy body dementia
Femoral n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs

39. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spastic paraparesis

40. When to give aspirin when patient on tPA after stroke
Femoral n lesion
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
Not within 24 hours; give afte 24-48 hours if patient stable
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

41. botulism
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
RBC count >6000
Antitoxin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

42. Blood transfusion in hypothermia
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Aphasia - neglect - agnosia - acalculia etc

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

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44. 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
Acetylecholinersterase inhibitors
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.
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

45. What mmse score suggest dementia
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;
<20; if patient scores >25 benign forgetfulness

46. differentiate lewy body dementia and vascular dementia
Despite the term neuroma they arise from schwann cells - schwanoma
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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

47. acoustic neuroma
Deficit in cranial nerve function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Despite the term neuroma they arise from schwann cells - schwanoma
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

48. best diagnosis for parkinsonim
Autospy gold standard
20%
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;
Not within 24 hours; give afte 24-48 hours if patient stable

49. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Tunnel vision - diaphoresis - nausea - pallor

50. phenytoin and OCP
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
Entacapone - COMT inhibitor
Reduced efficacy of OCP