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USMLE Step 2 CK Flash Cards > Neurology > Flashcards

Neurology Flashcards

1
Q

In which patients do you perform a head CT scan before lumbar punction when suspect meningitis?

A
  • Papilledema
  • Immunocompromised state
  • New-onset seizure (within one week of presentation)
  • History of CNS disease (mass lesion, stroke, focal infection)
  • Abnormal level of consciousness
  • Focal neurologic deficit
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2
Q

Most effective method to diagnose dural sinus thrombosis and findings on it

A

Cerebral venogram→bilateral infarcts along the posterior and anterior frontal lobes and parietal lobes, extending into the white matter (Sagital sinus infarcts)

*Example: Sagital sinus infarcts tend to cross arterial vascular territories and extend into the white matter

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3
Q

Other tests rather than the best initial one that can provide information about myasthenia gravis

A
  • Iced pack test (bedside)➡Application of an ice pack over the eyelids may improve symptoms
  • Tensilon test➡Edrophonium (anticholinesterase inhibitor)▶rapidly reverses symptoms
  • Abnormal single-fiber EMG and/or a decremental response to repetitive nerve stimulation
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4
Q

Important features to recognize dementia with Lewy bodies

A
  • Visual hallucinations
  • Spontaneous parkinsonism
  • Fluctuating cognition
  • REM sleep behavior disorder
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5
Q

What is Ramsay-Hunt syndrome?

A

Herpes zoster oticus➡reactivation of VZV in geniculate ganglion➡disrupting VII CN motor fibers, subsequent spread to VIII CN▶painful, erythematous, vesicular rash in auditory canal or auricle; ipsilateral facial paralysis; vestibular (vertigo, nausea/vomiting), hearing, taste disturbances.

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6
Q

What is multiple system atrophy (Shy-Drager syndrome)?

A
  1. Parkinsonism
  2. Autonomic dysfunction (orthostatic hypotension, erectile dysfunction, incontinence, disturbance bowel control, abnormal salivation, lacrimation and sweating, gastroparesis, etc.)
  3. Widespread neurological signs (cerebellar, pyramidal, lower motor neuron)➡bulbar dysfunction and laryngeal stridor may be fatal
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7
Q

Where is the stroke localization in a patient having right hemiparesis (with hyperreflexia) and left upper and lower facial weakness?

A

Left pons

*Left CN VI or VII palsy (LMN pattern facial weakness)

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8
Q

Best initial test and their results when suspect idiopathic intracranial hypertension

A
  • MRI→Normal or empty sella (70%)
  • MRV→Normal
  • Lumbar puncture→Opening pressure >250 mmH2O
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9
Q

Typical MRI/CT finding of high-grade (ex, IV grade) astrocytoma (glioblastoma)

A

Butterfly appearance with central necrosis, heterogenous serpiginous contrast enhancement

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10
Q

Neuropsychiatric manifestations of Wilson disease

A
  • Psychiatric→Depression, personality changes, psychosis, mania, anxiety
  • Neurologic→parkinsonism, dysarthria, choreoathetosis, ataxia
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11
Q

Risk factors of Multiple Sclerosis

A
  • Female, caucasian, HLA-DRB1
  • Location: USA, Europe, cold climate
  • Low Vitamin D levels
  • Smoking
  • EBV
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12
Q

Diagnostic and therapeutic (short-term) maneuver for cervical radiculopathy

A

Shoulder abduction test➡improve radicular symptoms when hand is placed on the top of the head

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13
Q

Ptosis, “down-and-out” gaze, diplopia and normal pupillary response in a patient with poorly controlled diabetes mellitus

A

Ischemic oculomotor (CN III) palsy [Diabetic ophthalmoplegia]

*Damage to the inner somatic nerve fibers while sparing the more peripheral parasympathetic fibers

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14
Q

Medications that may precipitate myasthenic crisis

A
  • Antibiotics: aminioglycosides, fluoroquinolones
  • Beta-blockers
  • Calcium channel blockers
  • Magnesium
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15
Q

Ulnar nerve neuropathy differences between wrist and elbow level injury

A
  • Wrist➡numbness, paresthesia at medial side of the hand + intrinsic hand weakness (“clumsiness”) [hypothenar, medial lumbrical, adductor pollicis]
  • Elbow➡⬇grip strength [flexor carpi ulnaris, medial portion of flexor digitorum profundus]
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16
Q

How you may differentiate guillain-barré syndrome vs tick paralysis?

A
  • GBS➡Autonomic dysfunction in 70% of patients (tachycardia, urinary tract retention, arrhythmias). CSF with albuminocytologic dissociation (⬆proteins, ⬇cells). Ascending symmetrical paralysis over days to weeks.
  • Tick-borne paralysis➡Ascending paralysis over hours to days, may be localized or more pronunced on 1 extremity. Look for and find the tick (next best step)
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17
Q

Etiology of tick-borne paralysis

A

Neurotoxin release: tick needs 4-7 days for neurotoxin release

*Remove the tick➡improvement in an hour, complete recovery in several days (Dermacentor app, Ixodes holocyclus)

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18
Q

Most common adolescent- and adult-onset muscular dystrophy and mode of genetic transmission

A
  • Classic myotonic dystrophy

- Autosomal dominant➡CTG repeat expansion on the DMPK gene

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19
Q

Main clinical presentation of classic myotonic dystrophy

A
  • Progressive skeletal muscle weakness➡face and distal extremities (forearms, hands, ankle flexors)▶muscle wasting➡ptosis, temporal wasting, limb muscle atrophy
  • Grip myotonia (hand)
  • Dysphagia
  • Conduction anomalies
  • Testicular atrophy/infertility
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20
Q

Which clinical manifestations might raise suspicion of cervical myelopathy?

A
  • Lower motor neuron (LMN) signs (Ex, weakness and atrophy) at the level of the lesion (arms)
  • Upper motor neuron (UMN) signs (Ex, hyperreflexia) below the level of the lesion (legs)
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21
Q

Most common cause of cervical myelopathy in older adults

A

Spondylosis➡canal narrowing➡spinal cord compression

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22
Q

Most important side effects of phenytoin

A
  • Phenytoin➡❌folic acid absorption in jejunum▶folic acid deficiency over weeks or months
  • Megaloblastic anemia
  • Gingival overgrowth/hyperplasia
  • Phenytoin➡❌bone and mineral metabolism (⬇bone density): calcium and vitamin D supplementation
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23
Q

Symptoms of papilledema due to increased intracranial pressure

A
  • Momentary vision loss that varies according to changes in head position
  • Large blind spot in visual fields
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24
Q

Treatment alternative for Parkinson disease when tremor is the dominant symptom and bradykinesia/rigidity are not significant

A

Anticholinergic therapy (Trihexyphenidyl)

*Limited to younger patients (≤65)→risk of adverse effects in older patients

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25
Q

Ocular manifestations of Neurofibromatosis type 1

A
  • Optic pathway glioma (15% of patients, age<6)➡asymptomatic or grow large to compress optic nerve▶⬇visual acuity, ❌color vision, optic nerve atrophy, proptosis, esotropia, optic disc pallor
  • Lisch nodules➡pigmented iris hamartomas
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26
Q

Most common psychiatric complication of multiple sclerosis

A

Depression

27
Q

Clinical presentation of anterior spinal artery syndrome

A

Motor weakness, loss of pain and temperature sensation below the lesion

*Proprioception and vibratory sensation are spared

28
Q

Clinical presentation of Transverse myelitis

A

Rapidly progressive myelopathy:

  • Motor weakness→from flaccid to spastic paralysis (UMNS)
  • Autonomic dysfunction→bowel/bladder incontinence or retention, sexual dysfunction
  • Sensory dysfunction→Pain, paresthesia, numbness with distinct sensory level (Ex, lowest spinal cord level with intact sensation). Proprioception and vibration compromised.
29
Q

Findings on the most useful studies for Transverse myelitis

A
  • MRI→Enhancement of =>1 contiguous spinal cord segments, usually in thoracic cord without evidence of compression
  • Lumbar puncture→CSF pleocytosis, elevated IgG
30
Q

Description of clinical presentation of cluster headache

A
  • Acute onset of unilateral retro-orbital pain (excruciating, sharp, steady)
  • Paroxysms onset during sleep, awakening, rapid peak, duration 90 minutes, 8 times daily, 6-8 weeks, remission up to 1 year
  • Redness of ipsilateral eye, tearing, nasal congestion, flushing, no visual changes
  • Ipsilateral Autonomic manifestations, “Horner Sx like”→ptosis, miosis, anhidrosis
31
Q

Treatment of acute attacks and prophylactic treatment of cluster headache

A
  • Acute attacks: 100% Oxygen, subcutaneous sumatriptan

- Prophylactic: Verapamil, Lithium

32
Q

Clinical presentation of cervical myelopathy

A
  • Neck pain radiating to occipital region
  • Extremity weaknes and numbness
  • Usually first➡Gait dysfunction
  • UMN signs (legs)➡slowly progressive spastic quadriparesis, hyperreflexia, Babinski sign, Hoffman sign (corticospinal tract lesion)
  • LMN signs (arms)➡muscle atrophy, hyporeflexia
  • Sensory changes➡⬇proprioception/vibration/pain sensation in hands or feet
  • Respiratory dysfunction
33
Q

What is the critical illness polyneuropathy?

A

Axonal injury of peripheral nerves➡weakness after prolonged stay in ICU (Ex, hyporeflexia)

*Complication of sepsis

34
Q

Which temperature change might trigger multiple sclerosis symptoms?

A

High environmental temperatures

*Address with cooling techniques

35
Q

Pharmacologic treatment for frequent/daily restless leg syndrome symptoms

A
  • First line: α2δ calcium channel ligands→Pregabalin, Gabapentin
  • Second line: dopamine agonists➡pramipexole, ropinirole, rotigotine, cabergoline
  • Last resource: Benzodiazepines (clonazepam), Opioids (codeine)
36
Q

Most reliable finding to differentiate between epileptic seizure and syncope

A

Tongue bitting - 32% sensitivity, 96% specificity

*Lateral bitting is even more specific. Frontal bitting might happen in syncope

37
Q

EEG finding in Creutzfeldt-Jacob disease

A

Triphasic periodic sharp-wave complexes.

38
Q

Clinical features that highly suggest cord compression

A
  • Sensory level
  • Vertebral tenderness
  • Hyperreflexia
39
Q

Most common causes of cord compression

A
  • Malignancy

- Infection (epidural abscess)

40
Q

Best first step when cord compression is suspected through clinical findings

A

Glucocorticoids➡⬇pressure on the cord

41
Q

In which cases do you expect to find xanthochromia in lumbar puncture?

A
  • Herpes simplex virus (HSV) encephalitis

- Subarachnoid hemorrhage (SAH)

42
Q

Prophylactic therapy for cluster headache

A
  • Verapamil

- Alternatives: lithium, valproic acid, topiramate.

43
Q

Treatment for Pseudotumor cerebri

A
  • Weight loss (obesity main risk factor)
  • Acetazolamide➡⬇production of CSF
  • Frequent lumbar punctures
  • Ventriculoperitoneal shunt if needed
44
Q

EEG pattern of absence epilepsy (petit mal seizures)

A

3-per second spike-and-wave discharges

45
Q

How do you differentiate CSF of SAH vs meningitis when finding elevated WBC?

A
  • SAH➡⬆WBCs (can mimic meningitis), normal WBC:RBC ratio
  • Meningitis➡⬆WBCs, ⬆WBC:RBC ratio

*Normal ratio: One WBC for every 500 to 1,000 RBCs (0,002 to 0,001)

46
Q

Which drugs are associated with the possibility of retarding the progression of Parkinson’s disease?

A

MAO inhibitors (Selegiline, Rasagiline)

47
Q

Treatment for Huntington’s disease

A

No cure or treatment for disease progression. Treat symptoms.

  • Dyskinesia: Tetrabenazine, Reserpine
  • Psychosis: Atypical antipsychotics (⬇risk for extrapyramidal side effects or tardive dyskinesia)
  • Depression: SSRIs
48
Q

Best first treatment choice for prevention of multiple sclerosis relapse

A

Glatiramer (copolymer 1) and Beta-Interferon

49
Q

Which chronic suppressive medication is most likely to cause worsening neurologic deficits in multiple sclerosis?

A

Natalizumab➡inhibitor of alpha-4 integrin

*Associated with progressive multifocal leukoencephalopathy (PML)

50
Q

Which is the diagnostic test for Amyotrophic lateral sclerosis?

A

Electromyography➡widespread denervation and spontaneous action potentials (fibrillation potentials)

51
Q

What treatments may prevent the progression of Amyotrophic lateral sclerosis?

A
  • Riluzole➡⬇glutamate buildup in neurons

- Edaravone (antioxidant)

52
Q

Most common complication of Facial nerve palsy. How do you avoid it?

A
  • Corneal ulceration by difficulty in closing the eye (especially at night)
  • Taping the eye shut and using lubricants
53
Q

What do you expect to find in the CSF of Guillain-Barré syndrome?

A

⬆Protein and normal cell count

54
Q

What is the most urgent step when you suspect Guillain-Barré syndrome?

A

Pulmonary function tests➡Assess for ⬇Forced vital capacity and peak inspiratory pressure➡earliest way to detect impending respiratory failure

55
Q

Best initial test for Myasthenia Gravis

A

Acetylcholine receptor antibodies (80%-90% sensitive, highly specific also)

56
Q

Which imaging test should you do in patients with Myasthenia Gravis?

A

Chest x-ray, CT or MRI (Best CT with contrast)➡look for thymoma or thymic hyperplasia

57
Q

Best initial treatment for Myasthenia Gravis

A

Neostigmine or Pyridostigmine➡long-acting cholinesterase inhibitor

*Consider Immunotherapy if remain symptomatic: Corticosteroids, Azathioprine

58
Q

How may you treat the adverse effects of initial myasthenia gravis therapy?

A

Glycopyrrolate➡anticholinergic❌muscarinic receptor▶⬇drooling and diarrhea from neostigmine or pyridostigmine

*It does not block nicotinic receptor

59
Q

Treatment of severe hyperacute crisis of myasthenia gravis

A

Profound weakness or respiratory involvement➡IVIG or plasmapheresis

60
Q

How do you differentiate Lambert-Eaton Myasthenic Syndrome (LEMS) vs Myasthenia Gravis?

A

Increased strength with increased use

*Deep tendon reflexes increase after exercise

61
Q

Clinical presentation of bupivacaine (local anesthetic) systemic toxicity

A
  • Blocks inhibitory neural pathways➡CNS overactivity▶perioral numbness, metallic taste, tinnitus▶▶generalized tonic-clonic seizures
  • Cardiovascular sympathetic activation (tachycardia, hypertension)▶fulminant cardiovascular collapse
62
Q

In which context may you find bupivacaine (local anesthetic) systemic toxicity?

A

Epidural anesthesia during labor➡epidural catheter may be inadvertently inserted into maternal circulation➡rapid systemic drug absorption

63
Q

What is the difference between heat exhaustion vs exertional heat stroke?

A

Exertional heat stroke has CNS dysfunction, heat exhaustion not

64
Q

How may you distinguish the cause of recurrent falls?

A

Pull test
- Abnormal when a patient requires multiple (≥3) steps backward to regain their balance➡impaired postural reflexes

*Early onset postural instability▶Parkinson-plus syndrome (multiple system atrophy, progressive supranuclear palsy, dementia with Lewy bodies)➡postural reflex dysfunction is typically a late finding (>3 years) in Parkinson’s disease

USMLE Step 2 CK Flash Cards (17 decks)

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