USMLE Step 2 CK - Neurology

migraine other preventive tx

CaB, tca, ssri, topiramate, valpro, botox (start if happens >3 /mo)

mg best initial test

achR abs. if neg get anti-MUSK abs. (better than edrophonium test as initial)

causes of stroke seen on ekg

af or a flutter. give warfarin or noac

mild pd rx

antiach (relieve tremor and rigidity), amantadine (esp in age>60 intolerant to antiach)

prevention of stroke

aspirin or clapidogrel

spasticity rx

baclofen, dentrolene, tizanadine

tension pres

bilateral band-like pressure, lasts 4-6 h, n pe

ess tremor, tremor occurs when

both rest and intention

tests to order in dementia

brain mri and vdrl or rpr and b12 plus methylmalonic acid and TFTs

brain abscess most accu test

bx (also determines organism and sens) (no lp)

brain abscess vs cancer

cannot wo bx

most common compli of cn7 palsy

corneal ulceration. for rx tape the eye shuut at night and use lubircants

spinal trauma rx

cs

brain abscess best initial test

ct or mri (ring or contrast enh lesion, edema mass effect. indistinguishable from ca)

sah best initial test

ct wo contrast

stroke best initial test

ct wo contrast (to exc hemorr)

locate the site of aneurysm

cta or mra or standard angio

restless leg rx

d agonists (eg premipexole)

severe pd (cannot take care of self, orthostatic) rx

d agonists (pramipexole, ropinirole) (or rotigotin) (best initial rx), levodopa plus carbidopa (most effective rx, on/off phenomena), comt inhibitors (only with levo plus carbi, when on off occurs or when rx is inadeq), maoi (single or plus levo/carbi, most likely to slow prog of disease), dbs (highly eff for tremors ad rigidity in some patients)

charcot marie tooth pres

distal weakness plus sens loss, wating in the legs, decr dtrs, tremor, high arch (pes cavus)

causes of peri neuropathy

dm (#1), uremia, alcohol, paraproteinemias

psychosis and confusion in very severe pd rx

do not stop pd drugs, give antipsy with least extrapyr effects (eg clozapine)

ad rx

donepezil, rivastigmine, galantamine (equal eff), memantine

when to get ct or mri in tension and migrain and cluster

dx is unclear or synd has recently started (to exc intracr mass)

tests for eval of causes of stroke

echo, ekg, holter, carotid duplex usg

charcot marie tooth most accu test

emg

bells palsy most accu test

emg (usually no need)

als dx

emg and incr cpk

mg most accu test

emg with repetitive stim

best chest imaging in mg

enh CT

ms when to use oligoclonal bands

equivocal or nonspec mri

migraine abortive rx

ergotamine or triptans

clsuter headache rx

ergotamine or triptans (suma, ele, almo, zolmi) or 100% o2 or predni or li or octreotide for abortive rx. verapamil or valpro for prophyl

who gets vzv vaccs

everyone age>60

management of epilepsy in general

first a single drug, if not enough switch to another if not enough add a second drug. if meds do not help surgical

tourette rx

fluphenazine, clonazepam, pimozide or other neuroleptics, methylphenidate, adhd rx

statins in stroke

give them to all stroke patients. target ldl is 70

ms drugs that prevent relapse and pros

glatiramer, beta interferon (these two are 1st choice), fingolimod, dimethyl fumarate, teriflunomide, natalizumab, mitoxantrone, aza, cyc

controlling risk factors for stroke

hba1c<7, lower bp, ldl<70, stop smoking

ms acute exacerb best initial rx

high dose cs (shortens duration)

stroke risk factors

hyperT, hyperlipidemia, dm, tobacco

nonhemorr stroke best initial rx

if <3h thrombolytics (eg tpa, if no history of bleeding), if >3h aspirin. if already o aspirin add dipyridamole or switch to clapidogrel. if >4.5 h may remove the clot with a cath retrieval (not angioplasty). telemetry to detect af or a flutter

pca stroke causes

ipsi sensory loss of face, cn9, cn10, contralat sensory loss of limbs, limb ataxia

status best initial rx

iv benzo (loraz or diaz)

myasthenic crisis rx

ivig or ppheresis

gbs rx

ivig or ppheresis (equally effective). no combo! no prednisone!

ekg on intracranial bleeding

large or inverted t waves suggestive of myocardial ischemia

asa infarc pres

loss of all func except post column, flaccid paralysis below, loss of dtr, evolves into spastic paraplegia several wks after, loss of pain and temp, babinski

sah most accu test

lp (necessary for only 5% that is fn on ct) (incr wbc mimics meningitis bot n wbc/rbc ratio which is 1/500-1000, beware of this ratio if changed, give ceftri plus vanco)

migraine pres

may be aura, photophobia. related to emos, menses and food. rarely aphasia, numbness, dysarthria

value of pft in gbs

may tell who will die. decr fvc and peak insp pres.

ms best initial test

mri

ms most accu test

mri

stroke most accu test

mri

syringo most accu test

mri

important eye finding in mg

n pupillary reflex

mg best initial rx

neo or pyrido (long acting)

gbs most spec dxtic test

nerve cond studies/emg (but takes 1-2 wks to become abn)

nf1 pres

neurofibromas, cn8 tumors, cafe au lait spots, meningiomas and giomas. no rx cn8 lesions may need decomp

pseu cerebri which tests to order

no dx without ct or mri plus lp (incr press but normal csf)

homonymous hemianopsia, eyes deviate to

normal sight, also to side of the lesion

hemorr stroke best initial rx

nothing

sah rx

nothing reverses hemorr. nimodipine (prevents subseq isch stroke), embolization (to prevent rebleed, >surgical clipping), vp shunt if hydroceph, phenytoin for seizure prophyl

tension headache rx

nsaids or other analgesics

single seizure begin epileptic drugs ?

only if status or focal neuro signs or abn eeg or lesion on ct, family history of seizures

trigem neur rx

oxacarbazepine or carbamazepine. also effective are baclofen and lamotrigine. if no resp gamma knife or surgical decomp

shy drager synd

pd predom with orthostasis

brain abscess rx

penicillin (use vanco if recent neurosurg) plus metro plus ceftri (or cefepime) for empiric. The switch to spec abx. 6-8 wk iv plus 2-3 mo oral

aca stroke causes

personality/cognitive defectes such as confusion, urinary incont, leg weakness

a patient comes to er with obvious gbs. most urgent step?

pft. decr fvc and peak insp pres means impending resp fail.

status persists, best rx

pheny or fospheny(less side effects, no hypoT and AV block so may give more rapidly). if no resp, phenobarb. if still no resp, paralyze the patient with succinylcholine, vecuronium or pancuronium to intubate and give midazolam or propofol.

sturge weber pres

posrt wine stain of the face, seizures, homoonymous hemi, hemiparesis, mental subnormality, calc of angiomas on skull xr. control seizures

gca rx

prednisone (even before bx)

bells palsy best initial rx

prednisone. 60 % no need. acycl sometimes added but no clear benefit

peri neuropathy best initial rx

pregabalin or gabapentin. others are tcas and anticonv.s

ess tremor rx

propranolol

migraine best preventive rx

propranolol (start if happens >3 /mo)

an epileptic with partial control over seizures drive to work best step?

recommend alternate means of transport. cannot confiscate the licence.

common causes of acq pd

repeated head trauma, antipsy (eg thorazine), encephalitis, reserpine, metoclo

als #1 death

resp failure

als rx

riluzole, baclofen for spasticity, cpap/bipap, tracheostomy, vent

postherpetic neuralgia, to reduce incidence

rx shingles with acycl, famci or valganci

tuber scler pres

seizures, psychomotor retardation, slow mental deterioration, adenoma sebaceum, shagreen patches, ash leaf patches, retinal lesions, cardiac rhabdomyomas. control seizures no rx

sah pres

suddent onset severe head, stiff neck, photophobia, fever, loss of consci(50%)

syringo best rx

surgical removal of tumor and drainage of fluid

carotid stenosis when to intervene

symp cerebrovasc disease plus stenosis >70%. dont if stenosis <50%. endarterectomy is better than angioplasty

hd rx

tetrabenazine for dyskinesia, antipsy (eg haloperidol, quetiapine) for psychosis

mg best next step if no control

thymectomy (markedly improves recurr, hard to control disease) under age 60, prednisone for age above 60. aza, tacro, cyc, myc to get off of cs. glycopyrolate to decrease drooling

pestherpetic neuralgia rx

try tca, gabapentin, pregabalin, carbamazepine or phenytoin until you find the right one. topical capsaicin. no clear routine rx

causes of stroke seen on echo

valvular path (surgical replacement), thrombi (warfarin with inr 2-3 or rivaroxaban or dabigatran), pfo

discont of epilepsy meds

wait until 2 yrs of seizure free. sleep deprivation eeg tells you if there is possibility to recur (not high sens)

spinal trauma pres

weakness and/or sensory def below, impaired sphincter func, loss of dtr then hyperreflexia

pseu cerebri rx

weight loss and acetazolamide (to decr csf prod) and prednisone if needed repeated lp to relieve press. if all fails vent.peri. shunt or optic nerve fenestration