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Neurology USMLE Step 3 > Section 5: Spine Disorders, Amyotrophic Lateral Sclerosis, Peripheral Neuropathies and Myasthenia Gravis > Flashcards

Section 5: Spine Disorders, Amyotrophic Lateral Sclerosis, Peripheral Neuropathies and Myasthenia Gravis Flashcards

1
Q

Name the likely spinal disorder based on these features:

  • Nontender
  • Tender
  • Tender and fever
  • Pain on walking downhill

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7426-7429). . Kindle Edition.

A
  • Lumbosacral Strain
  • Cord Compression
  • Epidural Abscess
  • Spinal Stenosis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7421-7425). . Kindle Edition.

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2
Q
  1. Diagnosis:
  • Defective fluid cavity in the center of the cord caused by trauma, tumors, or a congenital problem
  • It presents with loss of sensation of pain and temperature in the upper extremities bilaterally in a capelike distribution over the neck, shoulders, and down both arms.
  1. Diagnostic test
  2. Rx

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7431-7434). . Kindle Edition.

A
  1. Syringomyelia
  2. Diagnose with an MRI
  3. Treat surgically.
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3
Q
  1. Diagnosis
    * Metastatic cancer presses on the cord, resulting in pain and tenderness of the spine
  2. Initial test
  3. Most accurate test if the diagnosis is not clear from the history
  4. Initial Rx
  5. Definitive Rx

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7436-7440). . Kindle Edition.

A
  1. Cord Compression
  2. MRI
  3. Biopsy
  4. Steroids
  5. Rx underlying cause

Lumbosacral strain does not give tenderness of the spine itself.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7436-7440). . Kindle Edition.

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4
Q
  1. Diagnosis
  • Back pain
  • Tenderness
  • Fever
  1. Diagnostic test
  2. Rx
  3. Organism

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7440-7441). . Kindle Edition.

A
  1. Spinal Epidural Abscess
  2. MRI
  3. Oxacillin or nafcillin; large accumulation requires surgical decompression
  4. Staphylococcus
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5
Q
  1. Diagnosis
  • Leg pain on walking
  • Intact peripheral pulses
  • Pain is worse upon walking downhill, when the patient is leaning backward, but improved when walking uphill.
  1. Diagnostic test
  2. Rx

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7445-7448). . Kindle Edition.

A
  1. Spinal stenosis
  2. MRI
  3. Surgical decompression
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6
Q

List the CF of anterior spinal artery infarction

Rx

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7448-7449). . Kindle Edition.

A
  • Loss of all function except the posterior column (position and vibration sensation are intact)
  • Flaccid paralysis below the level of the infarction
  • Loss of deep tendon reflexes (DTRs) at the level of infraction
  • Evolves into spastic paraplegia several weeks later
  • Loss of pain and temperature
  • Extensor plantar response

No specific Rx

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7
Q

Dignosis:

  • Traumatic injury to the spine, such as a knife wound.
  • The patient loses ipsilateral position, vibratory sense, contralateral pain, and temperature.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7451-7453). . Kindle Edition.

A

Brown-Sequard Syndrome

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8
Q

A 58-year-old woman with metastatic breast cancer comes in with back pain. The spine is tender. She has hyperreflexia of the legs. What is the most urgent step?

a. X-ray
b. CT
c. MRI
d. Biopsy
e. Steroids
f. Chemotherapy
g. Radiation

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7454-7464). . Kindle Edition.

A

E. The most urgent step in the management of cord compression is to administer steroids as soon as possible and to relieve pressure on the cord. Imaging studies are done after steroids are given, if the diagnosis of cord compression is clear (as it is in this case with pain, tenderness, and signs of hyperreflexia in the legs).

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7454-7464). . Kindle Edition.

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9
Q

List the Upper Motor Neuron Signs

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7469-7479). . Kindle Edition.

A
  • Hyperreflexia
  • Upgoing toes on plantar reflex
  • Spasticity
  • Weakness

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7469-7479). . Kindle Edition.

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10
Q

List the Lower Motor Neuron Signs

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7469-7479). . Kindle Edition.

A
  • Wasting
  • Fasciculations
  • Weakness

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7469-7479). . Kindle Edition.

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11
Q

Amyotrophic Lateral Sclerosis is an idiopathic disorder of both upper and lower motor neurons

  1. Rx
  2. Benefit of Rx
  3. Class of drug

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7465-7467). . Kindle Edition.

A
  1. Riluzole, a unique agent that blocks the accumulation of glutamate.
  2. Prolong survival; delay the need for tracheostomy
  3. Glutamate inhibitor

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7465-7467). . Kindle Edition.

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12
Q

The most common cause of peripheral neuropathy by far is diabetes. A specific test, such as an electromyogram or nerve conduction study, is not necessary in the majority of cases.

  • Treatment of diabetic neuropathy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

A
  • Gabapentin or pregabalin

Tricyclic antidepressants are less effective and have more adverse effects

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

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13
Q

Carpal Tunnel Syndrome presents with pain and weakness of the first 3 digits of the hand. Symptoms may worsen with repetitive use.

  • Initial management

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

A

Splint

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14
Q

Radial Nerve Palsy also known as “Saturday night palsy,” this results from falling asleep or passing out with pressure on the arms underneath the body or outstretched, perhaps draped over the back of a chair.

Radial nerve palsy results in ——

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

A

Wrist drop

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15
Q

Peroneal Nerve Palsy. This results from high boots pressing at the back of the knee. It results in foot drop and the inability to evert the foot. May see “high boots” in the case.

Rx?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

A

There is no therapy. Peroneal nerve palsy resolves on its own.

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16
Q

7th Cranial Nerve (Bell’s Palsy) palsy results in hemifacial paralysis of both the upper and lower halves of the face. There is also loss of taste on the anterior two thirds of the tongue, hyperacusis, and the inability to close the eye at night. Hyperacusis results in the inability to control the stapedius muscle of the middle ear, which acts as a kind of “shock absorber” for sounds. Bell’s palsy is believed to result from a viral infection.

Rx of Bell’s Palsy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

A

Treat with steroids. It is not clear that acyclovir helps.

17
Q

Reflex Sympathetic Dystrophy. Also called chronic regional pain syndrome, reflex sympathetic dystrophy happens in a patient with previous injury to the extremity. Light touch, such as from a sheet touching the foot, results in extreme pain that is “burning” in quality.

Rx?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7480-7508). . Kindle Edition.

A
  • NSAIDs
  • Gabapentin, and
  • Occasionally nerve block.
  • Surgical sympathectomy may be necessary.
18
Q

Restless leg syndrome. This often comes to the health care provider’s attention when the bed partner comes in complaining of pain and bruises in the legs. The patient experiences an uncomfortable feeling in the legs, which is relieved by movement.

Treatment?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7506-7509). . Kindle Edition.

A
  • Pramipexole or ropinirole.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7506-7509). . Kindle Edition.

19
Q

A man comes to the emergency department with weakness in his legs that has been getting markedly worse over the last few days. He has weakness and loss of deep tendon reflexes in the legs. He recalls an upper respiratory illness about 2– 4 weeks prior that resolved. What is the most urgent step?

a. Steroids
b. Intravenous immunoglobulins
c. Peak inspiratory pressure
d. Intubation
e. Lumbar puncture

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7510-7532). . Kindle Edition.

A

C. This case is Guillain-Barré. Ascending weakness with loss of deep tendon reflexes is characteristic. Peak inspiratory pressure is the correct answer. The peak inspiratory pressure diminishes as the diaphragm is weakened. Peak inspiratory pressure predicts who will have respiratory failure before it happens. This is the most important factor in determining the need for therapy with either intravenous immunoglobulins (IVIG) or plasmapheresis. Combinations of these medications are not effective. Steroids are not effective. Lumbar puncture will show an elevated protein level with no cells.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7510-7532). . Kindle Edition.

20
Q

Myasthenia Gravis presents with weakness of the muscles of mastication, making it hard to finish meals. Blurry vision from diplopia results from the inability to focus the eyes on a single target. The case may classically report drooping of the eyelids as the day progresses.

  1. Best initial test
  2. Most accurate test
  3. Best initial therapy
  4. Other Rx options

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7510-7532). . Kindle Edition.

A
  1. Anti-acetylcholine receptor antibodies (ACHR)
  2. Clinical presentation and ACHR are more sensitive and specific than an edrophonium or “Tensilon” stimulation test
  3. Pyridostigmine or neostigmine
  4. Thymectomy: Use in patients < 60 if pyridostigmine or neostigmine do not work. Prednisone: If thymectomy does not work, or if there simply is no response to pyridostigmine or neostigmine. Azathioprine and cyclosporine are used to try to keep the patient off of long-term steroids.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7510-7532). . Kindle Edition.

21
Q

Subacute combined degeneration of the cord

  • List its causes
  • CF
A
  • B12 deficiency or neurosyphilis
  • position and vibratory sense are lost
22
Q

Diagnosis and Rx of the following condition:

  • Seizures
  • Progressive psychomotor retardation
  • Slowly progressive mental deterioration
  • Adenoma sebaceum (reddened facial nodules)
  • Shagreen patches (leathery plaques on the trunk)
  • Ash leaf (hypopigmented) patches
  • Retinal lesions
  • Cardiac rhabdomyomas
A
  • Tuberous sclerosis
  • No specific Rx; control seizures
23
Q

Diagnosis and Rx of following condition:

  • Neurofibromas (soft, flesh-colored lesions attached to peripheral nerves)
  • Eight cranial nerve tumors
  • Cutaneous hyperpigmented lesions (cafe au lait spots)
  • Meningioma or glioma
A
  • Neurofibromatosis (von Recklinghausen Disease)
  • No specific Rx. Eight cranial nerve lesions may need surgical decompression to help preserve hearing
24
Q

Diagnosis, test, and Rx of following condition:

  • Port-wine stain of the face
  • Seizures
  • Homonymous hemianopsia
  • Hemiparesis
  • Mental subnormality
A
  • Sturge-Weber syndrome
  • X-ray shows calcification of hemagiomas
  • Control seizures

Neurology USMLE Step 3 (10 decks)

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