Dit 2014 Step 2 Ck-1

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USMLE STEP 2 CK REVIEW

STUDY GUIDE

2014 EDITION

DOCTORS IN TRAINING*

STRUCTURED. FOCUSED.

AWESOME.

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Doctors In Training.com: U SM LE Step 2 CK Review, 2014 edition

Author: Brian Jenkins, M D

D octors In Training.com , LLC 1701 River Run, Suite #750 Fort W orth, T X 76107

All Rights Resei ved. 1 his test is protected by copyright No pari olthis I oh may be reproduced in any Ibi ni or by any means, including photocopying, or util bed by any storage and retrieval system, without written permission from the i pyt ight owner.

DISCLAIMER: THE AUTHO R DISCLAIMS ANY I.IAHIL ITY, LOSS, INJURY, O R DAMAGE INCURRED AS A CO NSEQ UENTS, DIRECTLY O R INDIRECT- LY. O r THE USE A N D APPI iCAT ION O F AMY O F THE CO N TEN T A N D MATE RIAL CO NTAIN ED IN THIS TEXT. ALTHOUGH THE INFORMATION IN THIS TEX I HAS BEEN CAREFULLY REVIEWED I OR CORRECTNESS. Wlf AUTHO R CA N N O T ACCEPT ANY RESPONSIBILITY FOR ANY ERRORS O R OMISSIONS THAT MAY BE MADE. THE A U 1IIO R MAKES N O W ARRANT Y, EXPRESS ORTMPLIED. AS TO THE COMPLETENESS. CURRENCY Oft ACCURACY o r I HE CONTENT'S OF THIS TEXT. THE INFORMATION CO NTAIN ED IN Ti-fTS TEXT SHO U LD N O T BE CONSTRUED AS SPECIF IC INSTRUCT IONS TOR INDIVIDUAL PATIENTS, MANUFACTURER'S PRODUCT INFORMATION A N D PACKAGE INSERTS SHOULD BE. REVIEWED TOR CURRENT INFORMATION, INCLUDING CO N TRA IN DICA I IONS. DOSAGES. AN D PRECAUTIONS.

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NOTES

COURSEVIEWING OPTIONS

The course consists of 169 instructional videos. Examples of 13, 15, 17, 21, 28, and 34 day plans are provided below for maximum flexibility to meet your personal study needs.

No. of Videos/Day Video Runtime/Day*

13-day plan 13 Approx. 4.5 hrs

15-day plan 11 Approx. 4 hrs

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RECOMMENDED COURSE ORDER

Al t h o u g h y o u h a v e t h e f l e x ib il it yt o v ie w t h e v id e o s in a n y o r d e r, w e s t r o n g l y r e c o m m e n d

THAT YOU WATCH THE VIDEOS IN THE ORDER IN WHICH YOUR DASHBOARD PRESENTS THEM REGARDLESS OF HOW MANY VIDEOS YOU VIEW IN A DAY.

1A Introduction

IB Neurology 1 - Normal Neuro Function

1C Neurology 2 - M eningitis

ID Neurology 3 - O ther C NS Infections

IE Neurology 4 - Headache I F Neurology 5 - T IA 1G Neurology 6 - Stroke 1H Neurology 7 - Hemorrhage Neurology 8 - Seizures i j Psychiatry 1 - Depression IK

■8

Psychiatry 2 - Antidepressants Psychiatry 3 - O ther M ood Disorders

2A Psychiatry 4 - Anxiety Disorders

2B Psychiatry 5 - Psychotic Disorders

2C Neurology 9 - Degenerative Disorders part 1

2D Neurology 10 - Degenerative Disorders part 2

2E Neurology 11 - Peripheral Disorders

2F Neurology 12 - Neoplasms and Sleep

2G Neurology 13 - Loss o f Consciousness

2H Neurology 14 - Pedi Neuro

21 Neurology 15 - Ophthalm ology part 1

2J Neurology 16 - Ophthalm ology part 2

2K Neurology 17 - Audiovestibular Disorders

3A Psychiatry 6 - Personality Disorders

3B Psychiatry 7 - Substance Abuse part 1

3C Psychiatry 8 - Substance Abuse part 2

3D Psychiatry 9 - O th er Psych Disorders

3E Psychiatry 10 - D elirium and Dementia

3F Psychiatry 11 - Pedi Psych

3G Endocrinology 1 - Type 1 Diabetes

3H Endocrinology 2 - Type 2 Diabetes

31 Endocrinology 3 - Insulin Therapy

3J Endocrinology 4 - Acute Complications o f Diabetes

3K Endocrinology 5 - C hronic Complications of Diabetes

R E C O M M E N D E D C O U R SE O R D E R

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RE C O M M E N D E D C O U R SE O R D E R

RECOMMENDED COURSE ORDER

4A Endocrinology 6 - Normal Thyroid Function and Hyperthyroidism

4B Endocrinology 7 - Hypothyroidism and Thyroid Cancer

4C Endocrinology 8 - Parathyroid Disorders

4D Endocrinology 9 - Pituitary Disorders

4E Endocrinology 10 - Cushing Syndrome and Hyperaldosteronism

4F Endocrinology 11 - O ther Adrenal Disorders

4G ER, ICU, Surgery 1 - Accidents and Injuries part 1

4H ER, ICU, Surgery 2 - Accidents and Injuries part 2

41 ER, ICU, Surgery 3 - Toxicology part 1

4J ER, ICU, Surgery 4 - Toxicology part 2

4K ER, ICU, Surgery 5 - Toxicology part 3

Hi

5A Cardiovascular 1 - Cardiology Basics

5B Cardiovascular 2 - Atherosclerosis

5C Cardiovascular 3 - Hypercholesterolemia

5D Cardiovascular 4 - Stable Angina

5E Cardiovascular 5 - Unstable Angina

SF Cardiovascular 6 - Myocardial Infarction

5G Cardiovascular 7 - Arrhythmias part 1

5H Cardiovascular 8 - Arrhythmias part 2

SI ER, ICU, Surgery 6 - Cardiovascular Emergencies

5J Cardiovascular 9 - H eart Failure

5K Cardiovascular 10 - Valvular Diseases

6A Cardiovascular 11 - Cardiomyopathies and Pericardial

Disease-6B Cardiovascular 12 - Myocardial Infections

6C Cardiovascular 13 - Hypertension

6D Cardiovascular 14 - Antihypertensives

6E Cardiovascular 15 - Shock

6F ER, ICU, Surgery 7 - Critical Care

6G Cardiovascular 16 - Vascular Conditions

6H Cardiovascular 17 - Vasculitis

61 Cardiovascular 18 - Pedi Cardiology

6J ER, ICU, Surgery 8 - Trauma part 1

6K ER, ICU, Surgery 9 - Trauma part 2

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RECOMMENDED COURSE ORDER

7A ER , ICU, Surgery 11 - Pre-O p and Post-Op Issues

7B ER , ICU, Surgery 12 - Surgical Emergencies and Transplantation

7C Pulmonology 1 - U R I

7D Pulmonology 2 - Lower Respiratory Infections part 1

7E Pulmonology 3 - Lower Respiratory Infections part 2

7F Pulmonology 4 - A R D S and A sthm a

' 7G Pulmonology 5 - C O P D

IBM

Pulmonology 6 - Neoplasms and Interstitial Lung Disease

71 Pulmonology 7 - Pulm onary Vascular Diseases

7J Pulmonology 8 - Pleural Diseases

7K Pulmonology 9 - Sleep Apnea & Pulm onary Surgical Concerns

7L Pulmonology 10 - Pedi Pulmonology part 1

7M Pulmonology 11 - Pedi Pulmonology part 2

8A Gastroenterology 1 - G I Infections

8B Gastroenterology 2 - Viral Hepatitis

8C Gastroenterology 3 - O ral and Esophageal Conditions

8D Gastroenterology 4 - G astric Conditions

8E Gastroenterology 5 - Small Intestine part 1

8F Gastroenterology 6 - Small Intestine part 2

8G Gastroenterology 7 - Large Intestine part 1

8H Gastroenterology 8 - Large Intestine part 2

81 Gastroenterology 9 - Colorectal Cancer and G I Bleeding

8J Gastroenterology 10 - Pancreatic Diseases

9A Gastroenterology 11 - Biliary Diseases part 1

9B Gastroenterology 12 - Biliary Diseases part 2

9C Gastroenterology 13 - Alcoholic Liver Disease and Cirrhosis

9D Gastroenterology 14 - O th er Hepatic Diseases

9E Gastroenterology 15 - Pedi G I Disorders

9F Epidemiology and Ethics 1 - Biostatistics

9G Epidemiology and Ethics 2 Research Studies

9H Epidemiology and Ethics 3 - Abstracts and Advertisements

91 Epidemiology and Ethics 4 - Ethics

9J G enitourinary 1 - Diuretics

9K G enitourinary 2 - Disorders of the Kidney p art 1

9L G enitourinary 3 - Disorders o f the Kidney part 2

R EC O M M EN D ED C O U R SE O R D E R

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R EC O M M EN D ED C O U R SE O R D E R

RECOMMENDED COURSE ORDER

10A Genitourinary 4 - Nephritic Syndromes

10B Genitourinary 5 - Nephrotic Syndromes

IOC Genitourinary 6 - Renal Failure

10D Genitourinary 7 - Acid-Base Disorders

10E Genitourinary 8 - Hyponatremia

10F Genitourinary 9 - O ther Electrolyte Disorders

10G Genitourinary 10 - Bladder and Ureteral Disorders

10H Genitourinary 11 - Male Reproduction part 1

101 Genitourinary 12 - Male Reproduction part 2

10J Genitourinary 13 - Pedi Urology

ll A Heme/Onc 1 - Anemia part 1

11B Heme/Onc 2 - Anemia part 2

11C Heme/Onc 3 - Anemia part 3

11D Heme/Onc 4 - Genetic Disorders of Hemoglobin

I IF Heme/Onc 5 - Leukocyte Disorders and Hypersensitivity

111 Heme/Onc 6 - Thrombocytopenia

11G Heme/Onc 7 - Coagulopathies and HyperCoagulable States

n i l Heme/Onc 8 - Hematologic Infections

H I Heme/Onc 9 - H IV

i n Heme/Onc 10 - H IV Treatment

U K Heme/Onc 11 - Myeloma and Lymphoma

11L Heme/Onc 12 - Leukemia

11M Heme/Onc 13 - Pedi Heme/Onc

12A Musculoskeletal 1 - Orthopedics part 1

12B Musculoskeletal 2 - Orthopedics part 2

12C Musculoskeletal 3 - Metabolic Bone Diseases

12D Musculoskeletal 4 - Infections, OA and Neoplasms

12E Musculoskeletal 5 - RA and Lupus

12F Musculoskeletal 6 - O ther Rheumatologic Diseases

12G Musculoskeletal 7 - Pedi O rtho

12H Dermatology 1 - Infections part 1

121 Dermatology 2 - Infections part 2

12J Dermatology 3 - Infections part 3

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RECOMMENDED COURSE ORDER

13A Dermatology 5 - Bullous Diseases and Neoplasms :' r v ; v :7

•

: i , v- : r i:;V .

13B Dermatology 6 - Plastics, Pigmentation and H air Loss

13C Gynecology 1 M enstrual Physiology

13D Gynecology 2 - Menopause

13E Gynecology 3 - Contraception

13F Gynecology 4 y Amenorrhea

13G Gynecology 5 - M enstrual Disorders part 1

13H Gynecology 6 - M enstrual Disorders part 2

131 Gynecology 7 - PC O S and Pelvic Prolapse

13J Gynecology 8 - Gynecological Infections and STDs

14A Gynecology 9 - Uterine and Cervical Neoplasms

14B Gynecology 10 - Vaginal and Ovarian Neoplasms

14C Gynecology 11 - Benign Breast Disorders

14D Gynecology 12 - Breast Cancer

14E Obstetrics 1 - Normal Pregnancy Physiology

14F Obstetrics 2 - Prenatal Care

14G Obstetrics 3 - M edical Complications part 1

14H Obstetrics 4 - Medical Complications part 2

141 Obstetrics 5 - M aternal D rug Use

14J Obstetrics 6 - Congenital Infections

1 § § 15A

15B

Obstetrics 7 - O bstetric Complications part 1

vasai

Obstetrics 8 - Obstetric Complications part 2

■ 15C

15D

Obstetrics 9 - Obstetric Complications part 3 Obstetrics 10 - Obstetric Complications part 4

15E Obstetrics 11 - L & D : Assessment of Fetus

1111

1SF Obstetrics 12 - L & D : Labor

15G Obstetrics 13 - L & D : M alpresentation and Cesarean Section

1511 Obstetrics 14 - Postpartum Care

151 Pediatrics 1 - Development

§§J§

15J Pediatrics 2 - Infancy to Adolescence

mm

15K 15L

Pediatrics 3 - Infections and Immune Disorders

Pediatrics 4 - Genetic Disorders

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N

eurology

1 N o rm al N euro F u n ctio n

2 M e n in g itis

3 O th e r C N S Infections

4 H ead ach e

5 T I A

6 Stroke

7 H em o rrh ag e

8 Seizures

9 D egenerative D isorders p a rt 1

10 D egenerative D isorders p a rt 2

11 P eripheral D isorders

12 N eoplasm s and Sleep

13 Loss o f C onsciousness

14 P edi N eu ro

15 O p h th alm o lo g y p a r t 1

16 O p h th alm o lo g y p a rt 2

17 A udiovestibular D isorders

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NORMAL NEURO FUNCTION

End o f Session Quiz

1. W h a t are the tw o m ost com m on locations o f aneurysms in the circle o f Willis?

2. W h ic h spinal cord lesion matches each o f the following descriptions? ° Fasciculations but also spastic paralysis

° Impaired proprioception + pupils do not react to light

° Bilateral loss of pain and temp below the lesion + hand weakness ° Bilateral loss o f vibration sense + spastic paralysis of legs then arms

° Bilateral loss of pain/temp below lesion + bilateral spastic paralysis below lesion + bilateral flaccid paralysis at the level of the lesion

3. A lesion to which area o f the brain is responsible for each o f the following clinical scenarios?

o Contralateral hemiballismus ° Hemispatial neglect syndrome ° Poor comprehension

• Poor vocal expression ° Personality changes

° Agraphia and acalculia (inability to write, inability to do mathematical calculations)

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MENINGITIS

3 Question Warm-Up

1 W here does each o f the following spinal tracts decussate/cross over?

» Dorsal columns

° Lateral corticospinal tract ° Spinothalamic tract

2. W h a t cerebral artery infarct can cause aphasia?

3. W h a t are the characteristic features o f Brown-Sequard syndrome?

Bacterial Meningitis

4. W hat are the common organisms and empiric IV antibiotic choices for bacterial meningitis based on the age of the patient?

Age Range Organisms Empiric Antibiotics

<1 month of age Preferred medications:

1) ampicillin +

2) cefotaxime or gentamicin 1 month to 60

years of age

Adult dosing shown here: 1) cefotaxime or ceftriaxone 2) vancomycin

3) dexamethasone IV q6hrs x4d (if over 6w of age)

>60 years, alcoholism, or debilitating comorbidities

1) ampicillin (Listeria coverage) 2) cefotaxime or ceftriaxone 3) vancomycin

4) dexamethasone IV q6hrs x4d

5. W hat is the rational for dosing dexamethasone prior to or along with the first dose of antibiotics for empiric treatment of bacterial meningitis?

° Dexamethasone, when given with or prior to the first dose of antibiotic, reduces the risk o f___________________________ in children with meningitis, especially in the cases o f ___________________________ .

° In adults with bacterial meningitis, dexamethasone reduces both morbidity and mortality, especially in the case o f _________________________ .

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£! —I CO

End of Session Quiz

7. W h a t organism is responsible for bacterial meningitis given each o f the

following findings on C S F examination? ° Gram-positive diplococci

° Gram-negative diplococci

° Small pleomorphic Gram-negative coccobacilli ° Gram-positive rods and coccobacilli

8. W h a t medication should be given to close contacts o f those w ith either meningococcal or H ib (Haemophilus influenzae type B) meningitis?

9. W h e n should a C T scan be perform ed as a next step instead o f an L P in a patient suspected o f having meningitis?

10. You suspect an A ID S patient may have meningitis. W h a t fungal infection should you be m ost concerned about?

11. W h a t is the treatm ent for fungal meningitis?

12. W h a t medications are used in combination in the treatm ent o f T B meningitis?

Viral Meningitis

6. W hat is the treatm ent for viral meningitis?

° Acetaminophen for pain ° IV fluids as needed

° Empiric antibiotics until___________________________

If younger than 3 years, severely ill or immunocompromised, continue empiric antibiotics until bacterial culture results confirm nonbacterial etiology

° ___________________ if suspicion of HSV or signs of encephalitis such as focal neurologic findings

Discontinue if HSV PCR and cultures are negative or alternative diagnosis is made

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OTHER CNS INFECTIONS

3 Question Warm-Up

1. W h a t is the most effective way to prevent bacterial meningitis in newborns?

2. W h a t other drug should be given just before or along w ith the first dose o f antibiotics in a patient suspected o f having bacterial meningitis?

3. W h a t is the most common location o f a berry aneurysm?

W est Nile Virus

° Birds are the reservoir, and mosquitoes are the vectors. Humans, horses and dogs are incidental hosts

° Sx: usually only headache, malaise, back pain, myalgia and anorexia for 3-6 days (“flu like”)

° Severe Sx in 1/150: meningitis +/- encephalitis including muscle weakness and flaccid paralysis (via anterior horn involvement), alterations in consciousness, possibly death ° D x:______________________________

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End of Session Quiz

5. A patient is adm itted to the hospital w ith the presumptive diagnosis o f viral meningitis. A n M R I o f the head shows lesions w ithin the right temporal lobe. W ith which pathogen is this pattern m ost consistent?

6. W h a t are the features o f Reye syndrome?

7. H o w should you treat a patient w ho has been bitten by an anim al suspected o f having rabies or by an anim al th a t cannot be observed for 10 days?

8. A patient is brought into the E R w ith progressive muscle weakness, retained sensation, headache, vomiting, neck pain and fever. C S F analysis shows increased lymphocytes and norm al glucose and protein. W h a t life-threatening complication can result i f this disease progresses?

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H E A D A C H E

HEADACHE

3 Question Warm-Up

1 H ow do the symptoms o f encephalitis differ from those o f meningitis?

2. Fill in the table o f C SF findings in cases o f meningitis caused by different types o f pathogens.

Pressure W BCs Glucose Protein

Healthy Bacterial Viral T B / fungal

3. W h a t other term should you remember when thinking about Reye syndrome?

4. W hat are the differences in the acute treatment of tension headaches, cluster headaches and migraine headaches?

Type of Headache Treatment

Tension headache NSAIDs

Cluster headache 100% 0 2 (6+ L/m in on non-rebreather for 20+ min) and

sumatriptan or dihydroergotamine (D H E 45)

Migraine headache Sumatriptan (or other triptan), dihydroergotamine (D H E

45), NSAIDs, and/or antiemetics (chlorpromazine,

prochlorperazine, metoclopramide) in varying combinations based on severity, nature of symptoms and patient’s history

S. W hat agents can be used for prophylaxis of migraine headaches?

: verapamil (often first-line b/c safe and well tolerated) propranolol, metoprolol (good choice if comorbid hypertension) amitriptyline, nortriptyline (good choice if comorbid depression, insomnia, pain syndrome)

--- : naproxen (good choice if menstrual migraine or comorbid osteoarthritis or other pain that could benefit from NSAIDs)

--- : valproic acid (good if history of bipolar disorder), topiramate, gabapentin

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X m > O >

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m Pseudotumor Cerebri

7. W hat are the characteristic features of pseudotumor cerebri?

° Young, obese woman

° Headaches — daily (worse in the morning), pulsatile, possible nausea/vomiting, possible retroocular pain worsened by eye movement

O

° Most worrisome sequela is vision loss ° C T scan:___________________________

0 CSF pressure elevated ( ______________ in non-obese patient,______________ in obese patient)

8. W hat treatm ent options are available for managing pseudotumor cerebri?

° Confirm absence of other pathology with C T and M R I of the head (r/o central venous thrombosis)

° Discontinue any inciting agents (e.g.,_______________________________ )

° ___________________________ in obese patients

o ___________________________ - first line (start 250mg qid or 500mg bid —> increase to 500mg qid to lOOOmg qid)

° Invasive treatment options - Serial lumbar punctures

- Optic nerve sheath decompression Lumboperitoneal shunting (CSF shunt)

6. W hat headache symptoms would lead you to suspect a brain tum or as a cause of a headache?

° Mild headache which progressively worsens over days to weeks ° New onset after age 50

° _________ ; worsened by bending, lifting, cough or Valsalva maneuver (increased intracranial pressure)

° Associated seizures, confusion, altered mental status

° Abnormal neurologic signs and symptoms (e.g., focal numbness or weakness) ° Disturbs sleep or presents immediately upon awakening

° Vomiting precedes headache

° Known systemic illness (e.g., cancer, HIV, or collagen-vascular disorder)

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What is the most likely cause of headache based on each of the following descriptions?

Made worse by foods containing tyramine Obese woman with papilledema

Jaw muscle pain when chewing Periorbital pain with ptosis and miosis Photophobia and/or phonophobia Bilateral frontal/occipital pressure Lacrimation and/or rhinorrhea Elevated ESR

“Worst headache o f my life”

Headache + extraocular muscle palsies Scintillating scotomas prior to headache Headache occurring either before or after orgasm

Responsive to 100% oxygen supplementation Frontal headache made worse by bending over Trauma to the head —> headache begins days after the event, persists for over a week and does not go away

E nd o f Session Q uiz

10. W h a t is the pattern o f pain in a migraine? In a tension headache?

11. A 27-year-old m an comes to the clinic because o f a progressively worsening headache. H e says th at he never used to have headaches until this one. H e adds that this one was easy to ignore at first but over the last few weeks has never let up and is increasing in severity. W h a t should be next for this patient?

12. W h a t would be the preferred antihypertensive in a patient w ith chronic hypertension and recurrent migraines?

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TIA

3 Question Warm-Up

1. A lesion to w hich area o f the brain is responsible for each o f the following clinical scenarios?

° Agraphia and acalculia ° Hemispatial neglect syndrome ° Personality changes

° Coma

2. M eningitis is diagnosed in a neonate. W h a t are the m ost likely organisms, and w hat is the empiric treatment?

3. W h a t should always be done prior to LP?

Transient ischemic attack (T IA )

4. W h at is the anticoagulant of choice in a patient with a history of stroke or T IA given each of the following scenarios?

° First T IA

° TIA/stroke due to atrial fibrillation ° TIA/stroke + coronary artery disease

° Repeat TIA/stroke while on aspirin

Carotid artery disease

5. W h at are the classic signs and symptoms of carotid artery stenosis?

o

° Transient ischemic attacks (TIAs)

° Reversible ischemic neurologic deficits lasting up to 3 days ° Amaurosis fugax (transient unilateral blindness)

° Cerebrovascular accidents (CVAs)

o ______________________ are not caused by carotid artery stenosis

6. W h at are the surgical indications for carotid endarterectomy?

° Symptomatic patients with narrowing o f______________________ ° Symptomatic men with narrowing o f______________________

° Asymptomatic patients with narrowing o f______________________ provided the fife expectancy is > 5 years and the surgeon has a perioperative complication rate of < 3%

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W hat are the important nonsurgical treatments for carotid artery stenosis?

° H T N control to < 140/90

° Dyslipidemia control to LDL < 100 mg/dL, H D L > 35 mg/dL, triglycerides < 200 mg/dL Lipid control with statins reduces stroke while other lipid-lowering drugs do not Niacin reduces carotid artery mtima thickness

Al IA diet

° DM control to fasting glucose < 126 mg/dL and H bA lC < 7% ° Smoking avoidance, consider varenicline (Chantix)

° Increased physical activity to at least 30-60 minutes 4 times weekly

6 Red wine consumption up to 2 drinks daily is beneficial. Avoidance of heavy drinking ° Evaluation for CAD and PAD

° ________________ (if history of TIA/stroke while on aspirin —» use Aggrenox or clopidogrel instead)

E nd o f Session Q uiz

8. List some major signs and symptoms o f a T IA .

9. W h a t anticoagulant would you give a patient who has just had his/her first TIA ? I f the patient had another T IA while on ASA, what would you add?

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STROKE

3 Question Warm-Up

1. A child presents to the E R w ith m ental status changes, hypoglycemia and

lesions suggestive o f chickenpox. W h a t is the m ost likely diagnosis?

2. W h a t type o f headache causes unilateral, severe periorbital headache w ith tearing?

3. C S F analysis shows low glucose, elevated neutrophils and Gram-positive diplococci. W h a t is the diagnosis?

4. W hat are the five main lacunar syndromes that may arise from a lacunar infarct?

Lacunar Syndrome Description

Weakness of the face, arm and leg on one side of the body + absent sensory or cortical signs (aphasia, neglect, apraxia, hemianopsia)

(M ost common, about 50% of lacunar strokes)

Sensory defect (numbness) of the face, arm and leg on one side of the body + absent motor or cortical signs

Ipsilateral weakness and limb ataxia out o f proportion to the motor defect, possible gait deviation to the affected side + absent cortical signs

W eakness and numbness o f the face, arm and leg on one side o f the body + absent cortical signs

Facial weakness, dysarthria, dysphagia and slight weakness and clumsiness o f one hand + absent sensory or cortical signs

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E nd o f Session Quiz

5. In what timeframe must thrombolytic therapy be instituted in cases of ischemic stroke?

6. W h a t is the principal cause o f a lacunar infarct?

7. A patient w ith a D V T develops a stroke. W h a t study would most likely identify the underlying etiology o f the stroke?

8. W h a t neurologic defects would be seen w ith an infarction o f the following arteries?

Anterior cerebral artery

M iddle cerebral artery

Posterior cerebral artery

Lacunar arteries

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HEMORRHAGE

3 Question Warm-Up

1. W h a t are the four most common sequelae o f meningitis in children?

2. W h a t does a ring-enhancing brain lesion on C T in a patient w ith seizures

suggest?

3. A 30-year-old w om an is in the office w ith a complaint o f facial pain. She

describes th a t whenever her face is lightly touched she experiences incredible electrical-like pain. W h a t is the first-line treatm ent for this condition?

4. W hat is the treatm ent for a subarachnoid hemorrhage?

° Discontinue all anticoagulants and reverse any anticoagulation

° Systolic blood pressure < only if cognitive function is intact (adequate cerebral

perfusion pressure) until the aneurysm is clipped or coiled to prevent rebleeding. If the cerebral perfusion pressure is not adequate, then lowering the BP will increase the risk of infarction.

- _____________________________ preferred

A void_____________________________ which can increase intracranial pressure ° ___________________________(a CCB) to prevent vasospasm

° Prevent physiologic derangements that may worsen brain injury - Avoid hypoxia and hyperglycemia

Maintain a normal pH, euvolemia and normothermia

° Phenytoin for seizure prophylaxis is controversial and generally avoided due to poorer outcomes.

° Ventriculostomy to monitor intracranial pressure in select patients ° Surgical__________________________ into aneurysm

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H E M O R R H A G E

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E nd o f Session Quiz

5. In which scenario is seizure prophylaxis w ith anticonvulsants recommended: parenchymal hemorrhage or subarachnoid hemorrhage (SAH)?

6. W h a t are 3 feared complications o f parenchymal hemorrhage?

7. W h a t are the most common causes o f an epidural hematoma and a subdural hematoma?

8. I f you suspect a patient has an epidural or subdural hematoma, should you perform a L P to confirm the diagnosis?

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SEIZURES

3 Question Warm-Up

1. C om paring ischemic stroke, intracerebral hemorrhage and subarachnoid hem orrhage, w hat are the different BP goals and B P medications?

BP goal BP medications

Ischemic stroke

Intracerebral hemorrhage

Subarachnoid hemorrhage

2. A 40-year-old m an presents w ith daily, unilateral retroorbital headaches associated w ith rhinorrhea and lacrimation. W h a t is the diagnosis, and w hat treatm ent w ill rapidly abort his headache?

3. You suspect an A ID S patient may have meningitis. W h a t specific C S F

preparation should be ordered in addition to the usual C S F analysis, G ram stain and culture?

4. W hich medications or medication withdrawals are known for causing seizures?

5. W h at seizure medications are used for prevention of each of the following types of recurrent seizures?

Seizure type Initial treatment of choice

G rand mal (tonic-clonic) valproate, carbamazepine, phenytoin, lamotrigine,

topiramate Partial

> valproate, topiramate Absence

Myoclonic

6. W hich seizure medication matches each of the following descriptions?

° Gingival hyperplasia

° D rag of choice for absence seizures ° Second choice for absence seizures ° Drug of choice for trigeminal neuralgia

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S E IZ U R E

S _{7. Which drugs are known for causing Stevens-Johnson syndrome?}

8. Which drugs are known for inducing the cytochrome P450 system, thereby speeding up the metabolism of other drugs such as O C P s and warfarin?

E nd o f Session Quiz

9. W h a t type o f seizure fits each description? Focal sensory or motor deficit with N O loss of consciousness

Focal sensory or motor deficit with impaired consciousness (commonly localized to temporal lobe on EEG)

Involves both hemispheres of brain with a pattern o f neuromuscular activation: tonic, clonic, tonic- clonic, myoclonic, or atonic. Loss o f consciousness present with postictal period

Characterized by a brief (few seconds) impairment of consciousness. No postictal period. Spike-and- wave pattern on EEG.

10. W h a t are the m ost common causes o f seizures in children aged 2-10 years?

11. W h at are the most common causes of seizures in young adults (18-35 years)?

12. Although benzodiazepines are used to end a seizure in status epilepticus, what is o f more concern in the initial treatment?

13. W h a t is the drug o f choice for absence seizures?

14. A 45-year-old man is brought to the E R for new-onset status epilepticus. W h a t are some o f the components o f the work-up to determine the cause o f epilepsy?

(34)

DEGENERATIVE DISORDERS PART I

3 Question Warm-Up

1. W h a t two side effects should a physician be aware o f when using atypical antipsychotics?

2. W h a t are the signs and symptoms o f a T C A overdose? H ow is it managed?

3. A patient is brought into the E R w ith headache, vomiting, neck pain and fever. There is progressive muscle weakness, but sensation is intact. C S F analysis shows norm al glucose and protein, b u t the C S F lymphocyte count is high. W h a t is the diagnosis?

4. W hat medications are used in the management of Parkinsonian symptoms?

° Levodopa + carbidopa

° ______________________(MAO-B inhibitor) used in early disease and has neuroprotective effects.

° Dopamine agonists:

- ________________________(ergot compound)

Non-ergot D3 stimulators — pramipexole, ropinirole, rotigotine (transdermal) - Apomorphine (subQ) — rescue therapy for sudden akinetic episodes

° _____________________to potentiate levodopa: entacapone, tolcapone ° _____________________for tremor: trihexyphenidyl, benztropine

° ________________ to increase dopamine release. Used as short-term monotherapy in mild disease.

(35)

W hat are the characteristic features of amyotrophic lateral sclerosis (A LS, Lou Gehrig disease)?

° Weakness but with normal sensation ° Initial presenting symptoms:

________________________ (80%) in hands, fingers, shoulder girdle, lower extremity (foot drop) Oh pelvic girdle

(20%)

° Upper motor neuron (UMN) signs and symptoms: movement stiffness, slowness and incoordination; spasticity and hyperreflexia (spastic paralysis); slowed rapid alternating movements; gait disorder

° Bulbar UMN signs and symptoms: dysarthria; dysphagia; pseudobulbar affect with inappropriate laughing, crying or yawning

° Lower UM N signs and symptoms: weakness, gait disorder, reduced reflexes (flaccid paralysis), muscle atrophy and fasciculations

° Cognitive defects: frontotemporal executive dysfunction

° Neuromuscular respiratory failure after months to years (average survival from time of diagnosis is 3-5 years)

W hat are the C s of Huntington chorea?

° CAG repeat disorder on chromosome Cuatro (4) Caudate andputamen atrophy on MRI Acetylcholine decrease

G A BA decrease ° Cognitive decline (dementia) ° Choreiform movements ° Cuarenta (40) = age of onset

E nd o f Session Quiz

7. W h a t medication is m ost commonly used to treat Parkinson disease?

8. W h a t brain lesion is seen in patients w ith Parkinson disease?

9. W h a t will an electromyogram reveal in ALS?

10. W h a t medication is used to treat ALS?

11. W h a t is the life expectancy once a patient is diagnosed w ith ALS?

(36)

DEGENERATIVE DISORDERS PART 2

3 Question Warm-Up

1. W h a t is the pattern o f pain in a migraine? In a tension headache?

2, W h a t is the treatm ent for nephrogenic diabetes insipidus caused by lithium toxicity?

3. A patient fell o ff a 20-foot-ladder and landed on his head. H is wife says although he seemed dazed initially, he recovered quickly and seemed “fine” for 2 or 3 hours, before becom ing confused, disoriented and somnolent. W h a t are the diagnosis, the underlying injury and th e treatment?

4. W h at are the usual components of a “dementia work-up” ?

5. W h at are the unique features of Lewy body dementia?

(37)

D E G E N E R A T IV E D IS O R D E R S PA RT 2

E nd o f Session Q uiz

7. A 66-year-old woman with forgetfulness and decreased bilateral parietal lobe

activity on P E T scan has w hat form o f dementia?

8. W h a t medications are used in the treatment o f Alzheimer disease?

9. H ow does one differentiate between vascular dementia and Alzheimer disease?

10. W h a t are two symptoms that should clue you in to the diagnosis o f multiple sclerosis (MS)?

11. W h a t is the most sensitive test for multiple sclerosis?

12. W h a t medication decreases the frequency o f relapses in patients w ith multiple sclerosis?

13. W h a t im portant neuronal tract is the first to be compressed and compromised in the case o f syringomyelia?

(38)

PERIPHERAL DISORDERS

3 Question Warm-Up

1. H o w do the features o f acute dystonia differ from tardive dyskinesia?

2. W h ich medication is used more than any other in the treatm ent o f Parkinson patients?

3. W h a t is the m axim um am ount o f tim e a TLA. may last?

4. W hat is the classic presentation of Guillain-Barre syndrome (GBS)?

° Symmetric muscle weakness that progresses over days to 4 weeks (usually 2 weeks) Usually beginning in the distal legs but may begin in the arms or facial muscles in 10% of cases

__________________________ requiring mechanical ventilation in ___________of cases

__________________________ and/or oropharyngeal weakness in __________ which may include bilateral facial muscle paralysis

° Autonomic dysfunction in 70% - usually________________________ ° Absent or depressed deep tendon reflexes

° Little if any change in sensation ° No fever at the onset of symptoms ° GBS may be preceded by:

Campylobacter jejuni diarrheal illness (about 20% of cases)

HIV infection CM V infection EBV infection - Mycoplasma infection - Other viral infections

Immunization (extremely rare)

5. How is the diagnosis of Guillain-Barre syndrome made in a patient with ascending muscle paralysis?

° Characteristic clinical presentation

° CSF analysis (elevated protein and normal WBCs)

(39)

P E R IP H E R A L D IS O R D E R

S _{6. W hat is the prognosis of a patient with Guillain-Barre syndrome?} ° Spontaneous regression and complete recovery by 1 year in 80-90% ° Relapse in 10%

° Prolonged disease with delayed or incomplete recovery in 5-10% ° Death despite ICU care in 5%

7. W hat is the treatment of Guillain-Barre syndrome?

° Hospitalization for respiratory monitoring including vital capacity, BP monitoring, cardiac monitoring (telemetry) and daily abdominal auscultation for ileus

° Mechanical ventilation required in 30% of patients

° ICU monitoring for autonomic dysfunction required in 20% of patients Equally effective at shortening time to independent walking by iSQfb Combining the two offers no additional benefit

° _______________________ are N O T recommended in the treatment of GBS. Previously the mainstay of therapy; new studies show absolutely no benefit.

8. W hat is required to make the diagnosis of Bell’s palsy? Clinical diagnosis:

° Diffuse involvement of the entire facial nerve —> facial muscle paralysis (upper and lower)

Rule out Lyme disease b y _________________ : tick bite, heart block, arthritis, vertigo, hearing loss

Rule out Otitis media b y__________________ Rule out stroke b y _______________________

° Acute onset (1-2 days) —> progressively worsening weakness for 3 weeks —» recovery within 6 months

° Anything other than the above presentation requires imaging (CT and/or M RI) and screening blood tests to rule out other pathology

(40)

W hat is the treatm ent for Bell’s palsy?

° Eye care to prevent corneal trauma Artificial tears hourly while awake Lubricating ointment qHS Patch covering the eye at night

° Glucocorticoids (e.g., prednisone 60mg daily x 1 week)

° +/- Valacyclovir lOOOmg tid x 1 week (acyclovir provides no additional benefit over glucocorticoids)

End of Session Quiz

10. W h a t test can help m ake the diagnosis o f myasthenia gravis?

11. H o w does Lam bert-Eaton syndrome differ from myasthenia gravis (M G ) on history and physical exam?

12. W h a t are the treatm ent options for benign essential tremor?

13. A 35-year-old w om an presents w ith ptosis and diplopia that worsens throughout the day. W h a t is the underlying problem?

14. W h a t is a classic presentation o f Guillain-Barre syndrome?

15. H o w do you treat Guillain-Barre syndrome?

(41)

NEOPLASMS AND SLEEP

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3 Question Warm-Up

1 W h a t two medications could be used for prophylaxis against meningococcal

meningitis?

2. W h a t two classes o f medication could be used both to treat chronic hypertension and also to prevent recurrent migraines?

3. H ow do edrophonium, neostigmine and pyridostigmine work in the treatment o f myasthenia gravis?

. W hat are the differences between nightmares and night terrors?

° Nightmares - during REM sleep, patients that appear to wake up are actually awake ° Night terrors - during non-REM sleep, patients that appear awake (and are frightened/

screaming, tachycardic and diaphoretic) are actually not fully awake, difficult to arouse and usually fall right back to sleep after the episode

(42)

W hat is required to make the diagnosis of narcolepsy?

° _______________________ (sudden loss of muscle tone) only occurs in narcolepsy and is virtually diagnostic when present

° Other causes of excessive daytime sleepiness are ruled out

Overnight polysomnogram (to r/o O SA and periodic limb movement disorder) Rule out sedating medications as a cause

° Multiple Sleep Latency Test - when given 4-5 opportunities to nap every 2 hours, narcolepsy patients fall asleep in less than 8 minutes

W hat is the treatm ent for narcolepsy?

° Avoidance of drugs that cause sleepiness

° Scheduled naps (once or twice a day for 10-20 minutes) ° Stimulants - _______________________ is first-line ° Support group attendance

° I f cataplexy —* venlafaxine, fluoxetine or atomoxetine

W hat medications are common in the treatm ent of insomnia? W hat makes each one unique?

M elatonin Non-addictive, O T C , vivid dreams, safe for < 3 months

Valerian O T C herbal remedy, studies show no benefit

A ntihistam ines (diphenhydramine, doxylamine)

Commonly used by patients first-line, associated with poor sleep quality, not for long-term use, anticholinergic side effects (avoid in the elderly)

Trazodone Antidepressant, decreases sleep latency, small risk of

priapism TC A s

(amitriptyline, doxepin)

Antidepressant, small risk of arrhythmias (obtain EKG prior to use), anticholinergic side effects (avoid in the elderly) Benzodiazepines: (temazepam, lorazepam, clonazepam, diazepam, chlordiazepoxide)

Addictive, short-term only (< 35 days)

Zolpidem Zaleplon

Act at the benzo receptor, short-term only (< 35 days), rebound insomnia when discontinued

Eszopiclone May be used long-term

Ramelteon Non-addictive because it works at melatonin receptors

instead of G A B A /benzo receptors, avoid if hepatic insufficiency, long-term studies are lacking

(43)

N E O P LA SM S A N D S LE E

P _{8. Restless Leg Syndrome}

° The sensation of unpleasant paresthesias that compels the patient to have voluntary, spontaneous, continuous leg movements that temporarily relieve the sensations. The discomfort worsens at rest, in the evening and/or during sleep. Sensation of “spiders or ants” on/in K et/calf muscles.

° Usually a primary, idiopathic disorder

° Secondary RLS can result from iron deficiency, end-stage renal disease, diabetic neuropathy, Parkinson disease, pregnancy, rheumatic diseases (RA), varicose veins, caffeine intake.

° Treatment: pramipexole or ropinirole qHS (or levodopa/carbidopa), iron replacement, avoidance of caffeine, clonazepam qHS, gabapentin, opioids

End o f Session Quiz

9. W h a t is the next step once a brain tum or has been identified on C T or M R I o f the head?

10. W h a t are the im portant characteristics o f neurofibromatosis type 1?

11. W h a t is the mechanism o f action o f the preferred medication in the treatment of restless leg syndrome?

12. W h a t E E G waveforms correspond to the different stages o f sleep? ° Awake

° Awake, relaxed, drifting off to sleep ° Stage N1

: • Stage N2 ° Stage N3 • REM

13. Benzodiazepines increase which stage o f sleep at the expense o f what other stages o f sleep?

14. W h a t are the two most common primary brain tumors in adults? W h a t are the 3 most common primary brain tumors in children?

(44)

LOSS OF CONSCIOUSNESS

3 Question Warm-Up

1. W h a t is the treatm ent o f acute dystonia and how does it differ from the treatm ent o f tardive dyskinesia?

2. W h a t E E G pattern is seen in cases o f absence seizures?

(45)

Syncope basics Causes:

° Reflex syncope

Vasovagal: associated with emotional stress, trauma, pain, sight o f blood, prolonged standing

Situational: associated with micturition, defecation, coughing, G l stimulation ° Carotid-sinus hypersensitivity: associated with head turning, shaving, tight collar ° Cardiogenic: associated with exertion, palpitations, chest pain, SOB

° Orthostatic

° Cerebrovascular: associated with prolonged loss of consciousness, seizures, neurologic deficits

° No identifiable cause

Work-up basics:

° Rule out orthostatic hypotension via tilt test on multiple occasions ° Rule out seizure by history and physical

More likely seizure: history of seizure, prodrome of deja-vu postictal confusion, tongue lacerations

More likely syncope: prodrome of lightheadedness or sweating, history of prolonged standing

Nonspecific: brief limb jerking, urine incontinence ° CBC, electrolytes, BUN/Cr, glucose

° Assess volume status

° Pulse oximetry and ECG

° Evaluation of medications

° In patients over 40 (without history of carotid disease or carotid bruits), rule out carotid sinus hypersensitivity with carotid sinus massage while on telemetry monitor

Also consider:

° Serial cardiac enzymes and ECGs x3

Especially if: > 45 years old, diabetes mellitus, smoker; prior myocardial infarction or > 2-3 risk factors

° Echocardiogram

Especially if: murmur exertional syncope or history of heart disease ° Cardiac stress test

° Bilateral carotid duplex

Especially if: > 65 years old, C A D , PVD or bruit ° 24-hour Holter monitor

Especially if: abnormal ECG, palpitations, heart disease or family history of sudden death

° C T head without contrast and EEG

Especially: if neurologic symptoms, new seizure, headache

W hat is the differential diagnosis for a patient presenting to the emergency room for loss of consciousness?

(46)

W hat should you think about for initial empiric therapy in a patient coming into the emergency room with loss of consciousness?

W hy is thiamine given in a glucose infusion to alcoholics with hypoglycemia?

Glucose adm inistration in the absence of thiam ine can theoretically exacerbate damage to the mammillary bodies and w orsen______________________________.

End o f Session Quiz

8. W h ic h cause o f syncope is consistent w ith each o f these historical items or physical exam findings?

W hile shaving

W hile singing in a choir concert W ith a positive tilt test after taking blood pressure medication

W ith prolonged loss o f consciousness

Preceded by palpitations

Type 1 diabetic interrupted while eating

9. W h a t test is used to confirm orthostatic hypotension?

10. W h a t measurements indicate a positive tilt test?

11. In an intact brainstem, the patient’s eye should move in which direction w ith ice water infusion into an ear canal?

12. W h a t are the elbows doing in decorticate posturing?

13. A patient is brought into the emergency room w ith loss o f consciousness. W h a t should be administered before empiric glucose infusion?

(47)

PEDI NEURO

i

3 Question Warm-Up

1. W h a t drugs when combined w ith SSRIs are known for causing serotonin syndrome?

2. W h ich commonly used antidepressant should be avoided in patients at risk for seizure?

3. A 60-year-old patient presents w ith an acute onset o f broken speech. W h a t type o f aphasia is this? W h a t lobe and vascular distribution have been affected? W h a t is the first step in the workup?

Arnold-Chiari Malformation

° Downward displacement of the cerebellar tonsils and medulla through the foramen magnum

° Type I is the most common type and is often asymptomatic. Manifestations may include headaches and/or cerebellar symptoms.

° Type II (of IV severity) is usually accompanied by other neurologic anomalies.

W hat other neurologic anomalies are associated with an Arnold-Chiari malformation?

W hat are some of the possible presenting features of cerebral palsy?

° Spastic features - spastic paresis of any or all limbs, clonus present ° Athetosis features - slow, writhing movements in distal muscles

° Choreiform features - rapid, irregular, unpredictable contractions of muscles in face or extremities

° Dystonic features - uncontrollable jerking, writhing or posturing

Infants have persistence of primitive reflexes, involuntary grimacing, tendency to drool and delayed psychomotor development.

° Ataxia - difficulty coordinating purposeful movements

° Atonic features - severe hypotonia present at birth with no future ability to stand or walk ° Neonates may show signs of encephalopathy including lethargy, decreased spontaneous

movement, hypotonia and suppressed primitive reflexes.

(48)

End of Session Quiz

7. W h a t is the preferred treatm ent for febrile seizures?

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8. W hich element o f the quad/triple screen is abnormal in cases o f neural tube defect?

9. W h a t neural tube defect matches each o f the following descriptions? Incomplete closure of the dorsal vertebral

arches, often at the lumbosacral junction Condition where the above defect is severe enough for there to be herniation of the meninges

A more severe defect in which the spinal cord and meninges have herniated through Failure o f closure o f the anterior portion of the neural tube resulting in lack o f forebrain, meninges and parts o f the skull

10. W h a t is the definitive treatm ent for persistent hydrocephalus?

II. Retinoblastoma can be detected from w hat part o f the physical exam?

12. W h a t is the next step w hen a retinoblastoma is suspected on PE?

13. W h a t does cerebral palsy look like in a neonate?

(49)

OPHTHALMOLOGY PART I

3 Question Warm-Up

] W h a t vitamin supplement is recommended to all sexually active women of

childbearing age? W h a t developmental defect is this preventing?

2. W h a t is the diagnosis o f a patient who has periods o f m ood disturbances while psychotic as well as periods o f psychosis w ith normal affect?

3. A n elderly patient presents to the E R w ith a headache and a dilated right pupil. D uring the history, she reports th at she fell at home 5 days ago. W h a t is the most likely diagnosis?

Describe what light reflexes will be seen in both eyes if the right optic nerve is damaged prior to the pretectal nucleus (A K A afferent defect).

° No constriction of either the left or right pupil when light is shone in the right eye ° Both pupils constrict if the light is shone in the left eye

Describe what light reflexes will be seen in both eyes if the right oculomotor nerve is damaged (A K A efferent defect).

° Right pupil will not respond to light shone in either the right or left eye ° Left pupil will constrict when a light is shone in either eye

W hat is amblyopia and what are the signs/symptoms?

° Decreased vision due to a disruption in the normal development of vision usually from strabismus, cataracts or refractive error prior to age 10

° Possible presentations: esotropia (inward deviation), exotropia (outward deviation), diplopia and/or refractive error not correctable with lenses

W hat is the most common cause of blindness in the following populations of adults in the US?

° Over age 55 ° Under age 55 ° Blacks of any age

(50)

8. W hat are the distinguishing features of bacterial, viral and allergic conjunctivitis?

Etiology Type of Discharge Other Features

Bacterial Purulent, copious, 24hrs a day

Viral (adenovirus)

Watery, eyelid may be sealed in am

May also have fever, URI, LA D , pharyngitis

Allergic Bilateral, watery eyelid may be

sealed in am

Pruritus, other allergy symptoms

9. W hat is the m ost likely cause of conjunctivitis appearing in the first 24 hours of life?

10. W hat causes of red eye most closely match each of the following statements?

° May indicate a collagen-vascular disorder

° Potential serious complication of corneal ulceration ° Colored halos

° Itching eye

° Preauricular lymph node enlargement ° “Dry eyes”

° Shallow anterior chamber

11. W hat are the classic features that distinguish orbital cellulitis from periorbital cellulitis?

12. W hat are the distinctions between a chalazion, a hordeolum and anterior blepharitis? W h at is the treatm ent for each?

Description Treatment

Chalazion Inflammation of internal

M eibom ian sebaceous glands (eyelid swelling)

Usually self-limiting but can be treated w ith surgical excision and/ or intralesional steroid injection Hordeolum

(stye)

Infection o f external sebaceous glands of Zeiss or M ol (tender, red swelling at the lid margin)

° H ot compress 3-4 times a day for 10-15 minutes

° I f unresolved in 48 hours, then I8cD

° +/- Antibiotic ointment q3 hours Anterior

blepharitis

Infection o f eyelids and lashes secondary to seborrhea (red, swollen lid margins + dandruff on lashes)

o W ash lid margins daily with shampoo

° Remove scales daily w ith cotton ball

° Antibiotic ointment qd to lid margins

[

3 5

]

O P H T H A LM O LO G Y PA RT I

(51)

End of Session Quiz

13. W h a t would be the visual field defect for a lesion o f the optic tract?

14. W h a t are the symptoms o f H om er syndrome? W h a t is the classic cause?

15. Does strabismus cause amblyopia or does amblyopia cause strabismus?

16. O n morning O B /G Y N rounds, a very concerned new mother asks you about her 12-hour-old newborn’s red eyes. W h a t is the likely reason for the baby’s red eyes?

17. W h a t is the next step in the management o f a patient who has sustained a chemical burn injury to the eye?

18. W h a t is the easiest way to distinguish a hordeolum from a chalazion?

(52)

OPHTHALMOLOGY PART 2

3 Question Warm-Up

1. W h a t C S F findings would you see in a case o f subarachnoid hemorrhage?

0 "O 1 H X > i-3 O i—

o

o -< T3 > 73

2. A young child has loss o f the red light reflex. W h a t is the diagnosis?

3. W h a t is considered first-line pharmacotherapy for depression?

4. W h at is the classic presentation of a patient who has a cataract?

° Painless progressive decrease in vision manifested by difficulty driving at night, reading road signs or reading fine print

° Usually bilateral, but often unilateral

° Nearsightedness is often an early manifestation

° Possible disabling glare in bright sunlight or from oncoming headlights (more likely with steroid-induced cataracts)

5. W h at is the treatm ent for acute angle-dosure glaucoma? Initial medications:

° Pressure-lowering eye drop regimen: 1 drop each one minute apart of 0.5% timolol (Timoptic), 1% apraclonidine (Iopidine) and 2% pilocarpine (Isopto Carpine) ° Acetazolamide 250mg two tabs once

° I f refractory to above combination:

- given IV once diagnosis confirmed by

ophthalmologist

Surgical intervention:

° Laser peripheral iridotomy - tiny hole is made in the periphery of the iris so that aqueous humor can flow into the anterior chamber

(53)

W hat is the treatment for a corneal abrasion?

° Thorough eye exam with removal of any foreign body by irrigation

° Topical antibiotics QID continued 3-5 days or until the eye is symptom free for 24 hours (ointment > drops) - erythromycin, sulfacetamide, ciprofloxacin or ofloxacin

° OTC lubricant (Refresh PM, Lacri-lube) as needed up to hourly

° Pressure patching is optional for___________ , and is____________ if a foreign body is present. There is no role for pirate patching.

° Pain control with systemic opioids (e.g., Tylenol #3) or ophthalmic NSAIDs (e.g., diclofenac, ketorolac)

° NEVER prescribe a topical anesthetic (OK to use during the initial exam) or topical steroids!

° 24hr follow-up for contact lens abrasion, abrasion >3mm or abrasion with diminished vision.

W hat disease would you suspect in a 35-year-old woman with new-onset rapid loss of vision and pain when moving the eye? How would you treat this?

W hat eye abnormalities might be seen in a patient with vitamin A deficiency?

° Night blindness or complete blindness ° Xerophthalmia

° Bitot spots (areas of abnormal squamous cell proliferation and keratinization of the conjunctiva)

(54)

End of Session Quiz

9. W h a t are some major clinical features o f acute angle-closure glaucoma?

10. W h a t is the major exam finding in open-angle glaucoma?

11. W h a t is the treatm ent for closed-angle glaucoma?

12. W ith which disorders m ight you see a cherry-red spot on the macula?

13. W h a t is the treatm ent for macular degeneration (M D )? W h a t is the treatment for retinal detachm ent (RD)?

(55)

AUDIOVESTIBULAR DISORDERS

3 Question Warm-Up

1. W h a t are the 5 main lacunar syndromes that may arise from a lacunar infarct?

2. W h a t is the typical complaint o f a patient w ith retinal detachment?

3. W h a t is the treatment o f choice o f m ania w ith psychosis?

When is observation without antibiotics appropriate for a child with acute otitis media?

According to 2013 A A P/A A FP guidelines, you may refrain from antibiotics and simply observe if:

° Age 6 months to 2 years + unilateral AOM without otorrhea + mild illness + appropriate follow-up available + antibiotics can be started promptly if symptoms worsen

° Age > 2 years + unilateral or bilateral AOM without otorrhea + mild illness + appropriate follow-up available + antibiotics can be started promptly if symptoms worsen

° In either case, the decision to observe without antibiotics should be made jointly between provider and parent/caregiver(s)

° Antibiotics should be started if improvement is not noted in 48-72 hours

W hat are the classic signs and symptoms of bullous myringitis?

Bullous myringitis is a bullous/vesicular inflammation of the tympanic membrane that may occur in association with acute otitis media. It typically manifests as follows:

» More painful than; usual acute otitis media ° Otoscopy: large, reddish vesicles on the TM

W hat is the treatment for bullous myringitis?

° ____________________ is a common organism —> treat with oral___________________ ° Topical analgesics

(56)

7. W hat are the diagnostic features of mastoiditis?

° Symptoms occur days-weeks after developing acute otitis media ° Erythema, edema, tenderness behind the ear

° External ear displaced

° Diagnosis made from C T scan of the mastoid process

8. W h at are the distinguishing characteristics of acute labyrinthitis?

° Acute onset of vertigo, nausea, vomiting and nystagmus - Auditory function preserved = vestibular neuritis

Hearing loss + above symptoms = labyrinthitis

° Single episode that lasts days to weeks (usually not longer than 2 weeks) ° Preceded by a viral URI

° Nystagmus: horizontal, suppressed with visual fixation and has a fast phase away from the affected side

0 Abnormal head thrust test: W hen examiner rapidly turns the patient’s head to the affected side, the patient is unable to maintain visual fixation

° Gait instability, but preserved ambulation ° Absence of focal neurologic defects

9. W h at is the treatm ent for acute labyrinthitis (vestibular neuritis)?

° Typically subsides spontaneously within weeks ° Corticosteroid taper shown to improve recovery

° Symptomatic treatment only indicated for the first 48 hours of illness E.g., scopolamine patch, meclizine, metodopramide or promethazine Long-term recovery is theoretically delayed if used long-term ° Vestibular rehabilitation exercises

° M R I if > 60 years of age, headache, focal neuro signs, vascular risk factors or sustained vertigo inconsistent with acute labyrinthitis (vestibular neuritis)

10. W h at is the m ost com m on cause of conductive hearing loss in adults? W hat is the m ost com m on cause of sensorineural hearing loss in adults?

° Conductive — otosclerosis ° Sensorineural — presbycusis

11. Cholesteatom a:

° Overgrowth of desquamated keratin debris within the middle ear space that may eventually erode the ossicular chain and external auditory canal

° Causes: negative middle ear pressure (chronic retraction pocket) from eustachian tube dysfunction or direct growth of epithelium through a T M perforation

° Commonly associated with chronic middle ear infection

° PE: grayish-white “pearly” lesion behind or involving the T M , conductive hearing loss, vertigo

° Treatment: surgical removal usually involving tympanomastoidectomy and reconstruction of the ossicular chain

(57)

A U D IO V E ST IB U LA R D IS O R D E R

S _{12. W hat is the treatment for Ramsay Hunt syndrome?}

Ramsay H unt syndrome is herpes zoster oticus and is treated as follows: ° Narcotic analgesia for pain relief

° Oral steroids to decrease inflammation

° Antiviral therapy with valacyclovir (highest efficacy), famciclovir or acyclovir

End of Session Quiz

13. W h a t are the important characteristics seen on otoscopic exam o f a patient with otitis media?

14. W h a t is the underlying cause o f benign paroxysmal positional vertigo (BPPV)?

15. Explain how the W eber test can help distinguish conductive hearing loss from sensorineural hearing loss.

Dit 2014 Step 2 Ck-1

USMLE STEP 2 CK REVIEW

STUDY GUIDE

2014 EDITION

DOCTORS IN TRAINING*

STRUCTURED. FOCUSED.

AWESOME.

TABLE OF CONTENTS

TABLE OF CONTENTS

TABLE OF CONTENTS

NOTES

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1

N o rm al N euro F u n ctio n

2 M e n in g itis

3

O th e r C N S Infections

4 H ead ach e

5 T I A

6

Stroke

7 H em o rrh ag e

8

Seizures

9 D egenerative D isorders p a rt 1

10 D egenerative D isorders p a rt 2

11 P eripheral D isorders

12 N eoplasm s and Sleep

13 Loss o f C onsciousness

14 P edi N eu ro

15 O p h th alm o lo g y p a r t 1

16 O p h th alm o lo g y p a rt 2

17 A udiovestibular D isorders

NORMAL NEURO FUNCTION

End o f Session Quiz

MENINGITIS

3 Question Warm-Up

z

End of Session Quiz

N

EU

R

O

LO

G

Y

OTHER CNS INFECTIONS

3 Question Warm-Up

End of Session Quiz

HEADACHE

3 Question Warm-Up

n

x

[

)

N

EU

R

O

LO

G

Y

E nd o f Session Q uiz

TIA

3 Question Warm-Up

I [ 'I ]