Neurology Study Guide

Transcription

1 Neurology Study Guide

2 Neurology Study Guide Oral Board Examination Review Teresella Gondolo, MD

3 Library of Congress Cataloging-in-Publication Data Gondolo, Teresella. Neurology study guide : oral board examination review / Teresella Gondolo. p. ; cm. Includes bibliographical references and index. ISBN (s/c : alk. paper) 1. Neurology Examinations, questions, etc. 2. Physicians Licenses United States Examinations Study guides. [DNLM: 1. Neurology Examination Questions. WL 18.2 G637n 2005] I. Title. RC346.G dc ISBN Printed on acid-free paper Springer Science Business Media, Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science Business Media, Inc., 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, are not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed in the United States of America. (APEX/EB) SPIN springeronline.com

4 Preface The idea of a book to help neurologists prepare for the oral part of the Neurology Board Examination stemmed from numerous exchanges with colleagues on how they prepared for this important exam. Nobody seemed to have the magic formula to maximize their chances of passing and there were wide disparities of opinion on what they considered the best preparation. Some recommendations were based on often inaccurate impressions, others were the distorted product of their stressful experience while taking the test. On one thing everyone seemed to agree: There is not a single book available that systematically addresses the specifics of this crucially important test. The task was daunting because the scope of knowledge required to pass the test is as wide as the field of clinical neurology itself. To make it relevant to the experience of the test it was clear that a good preparation needed to be based on practical advice on the technical aspects of the exam as well as on the proper attitude in taking it. Moreover, filling a void in the current neurology literature, an adequate preparation had to be based on cases and their discussion on evidence-based clinical literature. Although primarily conceived for neurologists preparing for part 2 of the exam, this book intends to provide interesting case-based material to practicing adult and child neurologists, educators, academicians, supervisors, residents, and medical students. The book is divided into two parts. Part 1 is devoted to practical tips on the exam s structure, its etiquette, and preparation. Particular emphasis is placed on reasons for failing the exam. Part 2 concerns itself with the adult and pediatric vignettes part of the oral Board. Each vignette is presented in a format similar to the one candidates find at the exam. The case is then comprehensively formulated with a differential diagnosis, most likely diagnosis, and treatment recommendations. Where relevant, potential pitfalls, dos and don ts, musts and shoulds, and frequently asked questions complement the case discussion. TERESELLA GONDOLO, MD

5 Foreword What many Neurology residents do not realize is that they are preparing for the oral board examination every day. Presentations at rounds, at conferences, and even informal discussions regarding differential diagnosis and potential treatment plans are the stuff of the oral boards. Anxiety about the boards, however, is common to almost all trainees. And is doesn t seem to get better even with increasing clinical experience. One reason for this anxiety is that the Boards are shrouded by a veil of anecdotal experiences and myth, passed down with a variable degree of embellishment and probably a lot of inaccuracy. In fact, they are a highly structured and practical exercise in assuring the basic competence newly minted Neurologists. There is no magic formula for passing solid training, broad experience and clear thinking are all basic requirements. But a prescription for failure is a lack of preparation, which ideally includes not only knowledge of Neurology, but also an understanding of what is expected by the examiners. The exam structure provides relatively little time to present oneself (to a group of strangers, no less) as a competent and caring physician. Preparing for this interaction is essential. Many training programs have instituted mock oral board examination in order to better prepare trainees specifically for the exam. A formal syllabus for this exercise has been lacking. In this book Dr. Gondolo provides that syllabus, with a clear description of what to expect when taking the boards, and practical guidelines for how (and how not) to approach the exam. Examinees should pay careful attention to Part I, the part not covered during clinical Neurology training. Here Dr. Gondolo outlines clearly the structure of the oral board exam, including information on the examiners themselves: who are they and what are their expectations? This is also a guidebook of dos and don ts for the exam process that should be taken seriously. For example, dress in a businesslike fashion, get sufficient sleep before the exam, never argue with your examiner, and (when possible) focus your discussion on topics for which you have significant knowledge. The section on Reasons for Failing provides useful test-taking tips even for the smartest and most accomplished Neurologists. Dr. Gondolo reminds us that the approach to a case in Neurology should always be structured and organized. Follow this path with each and every case: 1) localization, 2) differential diagnosis, 3) diagnostic workup, and 4) management plans. Straying from this path puts you at risk for overlooking essential information that could be important in convincing the examiner of your competence. Perhaps the most important function of the Boards is discussed under the heading of The safety factor. First and foremost, the examiner is charged with the task of weeding out unsafe practitioners. Think carefully before suggesting a diagnostic test that may be risky, and never jump to a trivial diagnostic conclusion without first systematically excluding the more serious considerations. Part II is a concise and sensible study guide of Neurologic disorders and treatments that serves as a review for board examinees, but also as a teaching tool and reference guide for more junior trainees and medical students. The case studies presented are typical of those that may be encountered during the Vignette portion of the exam, and thus are good tools for study. What advice can I provide for the Neurologist about the take the oral board exams? Prepare well, play to your strengths, be considerate of your patients and your examiners, and get a good night s rest. You ve trained long and hard for this moment make the most of it! JONATHAN D. GLASS, M.D. Professor of Neurology and Pathology Director, Neurology Residency Training Program Emory University School of Medicine Atlanta, Georgia

6 Contents Preface... v Part 1 1 General Information... 3 The Candidate... 3 Presenting Yourself... 3 The Day You Arrive... 4 The Examiners... 4 Structure of the Examining Team... 4 Training of Examiners... 4 How Examiners Plan for the Session... 4 Grading... 5 Your Interaction with the Examiners... 5 The Anxiety Factor... 6 Hints for Dealing with Anxiety... 6 Information on the Board The Live Patient Examination... 9 The Room... 9 The Time Factor: 30-Minute History and Neurological Examination... 9 The Tool Box (Your Medical Instruments) The Patient Differential Diagnosis and Discussion of Treatment Options Your Interaction with the Patient The Difficult Patient The 30-Minute Neurological History And Examination The Art of History Taking The Neurological Examination The 30-Minute Case Discussion and Additional Questions The Vignette Adult Vignettes How to Approach a Vignette Adult Vignette Topics (Varies) The Last Ten Minutes The Candidate Without a Clue The Pediatric Vignette Age Categories How to Prepare for the Exam Courses Books Practice Reasons for Failing A Candidate s Story... 25

7 viii Contents The Safety Factor The Information Factor The Differential Diagnosis Factor Localization of the Lesion Determining the Temporal Factor Poor Planning and Treatment The Variability Factor Part 2 6 Peripheral Nervous System Disorders Motor Neuron Disease Amyotrophic Lateral Sclerosis Progressive Muscular Atrophy Bulbar Palsy Kennedy s Syndrome Peripheral Neuropathies Guillain-Barré Syndrome Chronic Inflammatory Demyelinating Polyradiculoneuropathy Miller Fisher Syndrome Disorders of the Neuromuscular Junction Botulism Lambert-Eaton Myasthenic Syndrome Myasthenia Gravis Brachial Plexopathy Femoral Neuropathy Postpartum Plexopathy Mononeuritis Multiplex Inflammatory Myopathies Polymyositis Dermatomyositis Inclusion Body Myositis Cerebrovascular Disorders Sinus Thrombosis Sagittal Sinus Thrombosis Subarachnoid Hemorrhage Cerebellar Hemorrhage Cerebal (Lobar) Hemorrhage Posterior Circulation Disorders Wallenberg s Syndrome Vertebrobasilar Artery Syndrome Proximal Basilar Artery Occlusion Posterior Cerebral Artery Infarction Weber s syndrome Carotid Artery Disease Carotid Artery Dissection Carotid Cavernous Fistula Temporal Arteritis Stroke Therapy Movement Disorders Multiple System Atrophy Progressive Supranuclear Palsy Wilson s Disease... 77

8 Contents ix Parkinson s Disease Dementia with Lewy Bodies Pick s Disease and Frontotemporal Dementia Huntington s Disease Tumors Pineal Tumors Acoustic Neuroma Pituitary Adenoma Pseudotumor Cerebri Limbic Encephalitis Meningeal Carcinomatosis Paraneoplastic Cerebellar Degeneration Olfactory Groove Meningioma Infections Herpes Simplex Encephalitis Herpes Zoster Vasculitis Progressive Multifocal Leukoencephalopathy Creutzfeld-Jacob Disease Lyme Disease Neurocysticercosis Cytomegalovirus Polyradiculopathy Parasitic Infections HTLV-1 Myelopathy Headache and Facial Pain Painful Ophthalmoplegia Subdural Hematoma Migraine Headache Cluster Headache Trigeminal Neuralgia Facial Palsy Adult Seizures, Neuro-otology, and Sleep Disorders New Onset Seizures in Adults Temporal Lobe Epilepsy Status Epilepticus in Adults Meniere Syndrome Narcolepsy Multiple Sclerosis Multiple Sclerosis Optic Neuritis Syringomyelia and Syringobulbia Transverse Myelitis Neurological Complications of Systemic Disorders Wegener s Granulomatosis Neurological Complications of Rheumatoid Arthritis Neurological Complications of Malabsorption Neuroleptic Malignant Syndrome Vitamin B 12 Deficiency Neurological Complications of Diabetes

9 x Contents 15 Toxic and Metabolic Disorders Wernicke-Korsakoff Syndrome Delirium Tremens Toxemia of Pregnancy Pediatric Epilepsy Neonatal Seizures Infantile Spasms and Tuberous Sclerosis Absence Seizures Febrile Seizures Juvenile Myoclonic Epilepsy Lennox-Gastaut Syndrome Benign Childhood Epilepsy with Centrotemporal Spikes Status Epilepticus Pediatric Brain Tumors Brainstem Glioma Pediatric Neuromuscular Disorders Hypotonic Infant Spinal Muscular Atrophy Type Spinal Muscular Atrophy Type Spinal Muscular Atrophy Type Muscular Dystrophies Duchenne s Muscular Dystrophy Other Muscular Dystrophies Dermatomyositis Infantile Botulism Neonatal Transient Myasthenia Gravis Charcot-Marie-Tooth Disease Facioscapulohumeral Muscular Dystrophy Myotonic Dystrophy Periodic Paralysis Fabry s Disease Metabolic Myopathies McArdle s Disease Acid Maltase Deficiency Mitochondrial Disorders Mitochondrial Encephalomyopathy Sleep Disorders: Kleine-Levin Syndrome Congenital Defects: Mobius Syndrome Pediatric Ataxia Ataxia-Telangiectasia Friedreich s Ataxia Posterior Fossa Tumor as Cause of Chronic Ataxia Acute Ataxia Pediatric Cerebrovascular Disorders Paradoxical Emboli Homocystinuria Cerebral Hemorrhage Acute Hemiplegia Subdural Hematoma

10 Contents xi Headache Basilar Migraine Ophthalmoplegic Migraine Pediatric Neurocutaneous Disorders Neurofibromatosis Pediatric Movement Disorders Huntington s Disease Sydenham s Chorea Dystonia Musculorum Deformans Tic Disorders Pediatric Neurometabolic Disorders Tay-Sachs Disease Krabbe s Disease Metachromatic Leukodystrophy Neuronal Ceroid Lipofuscinosis Adrenoleukodystrophy Pediatric Infections Subacute Sclerosing Panencephalitis Gradenigo s Syndrome Neonatal Meningitis Index