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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. MMSE score of less than 24
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Femoral n lesion
82% specific for dementia

2. When to use brain spect scintigraphy to confirm brain death
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Construction apraxia; lesion in non dominant parietal lobe (right)
Propranolol or primidone
It patient has electrolyte imbalance and hypothermia

3. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebral palsy; dx mri
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MS

4. anerior and anteriomedial thigh paresthesia - decreased DTR
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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.
Femoral n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;

5. How to tx lewy body dementia
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Follows viral illness; vertigo - tinnitus - nausea. self limiting

6. Should we tx htn in acute ischemic stroke

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7. Unable to copy of matchstick - unable to dress up
Despite the term neuroma they arise from schwann cells - schwanoma
Construction apraxia; lesion in non dominant parietal lobe (right)
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Aspirin - control HTN and swallow eval before giving any oral meds

8. differentiate wenicke and korsakoff
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MS
82% specific for dementia

9. differentiate picks and huntington
Deficit in cranial nerve function
Aspirin - control HTN and swallow eval before giving any oral meds
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
Distal lower motor neuron disease

10. When to give aspirin when patient on tPA after stroke
<20; if patient scores >25 benign forgetfulness
Taper gradually to prevent seizure relapse
MS
Not within 24 hours; give afte 24-48 hours if patient stable

11. Patient with carbamazepine; What should be advice?
82% specific for dementia
90% of right handed and 60% of left handed persons; speech and language function
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
Difficulty in writing - calculating - distinguishing left and write

12. differentiate lewy body dementia and vascular dementia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Botulism has descending paralysis in contrast othere have ascending paralysis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

13. earliest sign of phenytoin toxicity
Propranolol or primidone
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

14. How to differentiate dementias
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
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

15. contraindication of sumatripta
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Diabetes insipidus
Nystagmus on far lateral gaze
Coronary artery disease

16. women with unilateral eye pain; neurlogic symptoms here there at different times
Taper gradually to prevent seizure relapse
Acetylecholinersterase inhibitors
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

17. craniopharyngioma
Autospy gold standard
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
Diabetes insipidus

18. How to perform 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
Entacapone - COMT inhibitor
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

19. impaired vibration and increased DTR
Reduced efficacy of OCP
Vitamin B12 deficiency
Autospy gold standard
Acetylecholinersterase inhibitors

20. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Aspirin - control HTN and swallow eval before giving any oral meds
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

21. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tunnel vision - diaphoresis - nausea - pallor
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

22. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Cerebellar lesion
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

23. dominant parietal lobe on the left side
Clonidine will take care both high bp and withdrawal
Obturator n lesion
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
90% of right handed and 60% of left handed persons; speech and language function

24. 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
Cholinesterase inhibitor; and antiparkinsonism drugs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

25. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Femoral n lesion
Spastic paraparesis
Verapamil
Clonidine will take care both high bp and withdrawal

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

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27. botulism
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Antitoxin
Despite the term neuroma they arise from schwann cells - schwanoma
Lesion in nondominant temporal lobe

28. impaired hepatic conjugation of billirubin
Coronary artery disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Gilberts disease
90% of right handed and 60% of left handed persons; speech and language function

29. oligoclonal band in CSF
20%
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Aspirin - control HTN and swallow eval before giving any oral meds
MS

30. How to prevent prevent frequency of MS exacerbation
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
20%
Aspirin - control HTN and swallow eval before giving any oral meds
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

31. How to differentiate traumatic LP and SAH
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

32. What is can be used cluster headache prevention
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Despite the term neuroma they arise from schwann cells - schwanoma
Acetylecholinersterase inhibitors
Verapamil

33. impaired perception of complex sounds
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor
Lesion in nondominant temporal lobe
Reduced efficacy of OCP

34. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Deficit in cranial nerve function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion
90% of right handed and 60% of left handed persons; speech and language function

35. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Cerebellar lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

36. When to start fibrinolytic therapy in stroke patient?
Verapamil
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acetylecholinersterase inhibitors
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

37. When headache is presenting complaint of brain tumor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Tunnel vision - diaphoresis - nausea - pallor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Construction apraxia; lesion in non dominant parietal lobe (right)

38. dementia plus urinary incontinence
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Normal pressure hydrocephalus
90% of right handed and 60% of left handed persons; speech and language function
Construction apraxia; lesion in non dominant parietal lobe (right)

39. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

40. medial thigh sensory loss and weakness in addcution
Taper gradually to prevent seizure relapse
EPV - campylobacter - HSV
Obturator n lesion
Cerebral palsy; dx mri

41. acoustic neuroma
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Despite the term neuroma they arise from schwann cells - schwanoma
90% of right handed and 60% of left handed persons; speech and language function

42. What percent of dementia is reversible
Aphasia - neglect - agnosia - acalculia etc
20%
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Normal pressure hydrocephalus

43. brain stem lesion
Deficit in cranial nerve function
Not within 24 hours; give afte 24-48 hours if patient stable
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

44. cluster headache
Aphasia - neglect - agnosia - acalculia etc
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

45. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Taper gradually to prevent seizure relapse

46. Acute onset of left arm weakness
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
Entacapone - COMT inhibitor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

47. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Aphasia - neglect - agnosia - acalculia etc

48. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Normal pressure hydrocephalus
Taper gradually to prevent seizure relapse
Follows viral illness; vertigo - tinnitus - nausea. self limiting

49. Why V12 deficient develop hypokalemia after tx with b12
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
EPV - campylobacter - HSV
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

50. excessive elevation of legs during walking (toe touch floor earlier than heels)
Acetylecholinersterase inhibitors
Distal lower motor neuron disease
Difficulty in writing - calculating - distinguishing left and write
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal