Clinical Neurology

Clinical Neurology - Handbook (PDF)

Objectives

I. Knowledge and Life-Long Learning

By the end of the clerkship, the student will demonstrate the ability to:

• Organize clinical data from patient interviews and neurological exams to hypothesize lesion localization and neurologic diagnoses
• Develop thorough neurologic differential diagnoses based upon patient data
• Perform and document a neurologic examination including a
  -Comprehensive neurologic exam (Appendix 1)
  -Screening neurologic exam (Appendix 2)
  -Neurologic examination in patients with altered level of consciousness (Appendix 3)
• Recognize and interpret abnormal findings on a neurological exam

By the end of the clerkship the student will be able to recognize the general principals governing:

• Localization -Understand the general principles differentiating lesions at the following levels
  -Cerebral hemisphere
  -Posterior fossa
  -Spinal cord
  -Nerve root/Plexus
  -Peripheral nerve (mononeuropathy, polyneuropathy, and mononeuropathy multiplex)
  -Neuromuscular junction
  -Muscle

• Approach Symptom Complexes – a systematic approach to the evaluation and differential diagnosis of patients who present with:
  -Focal weakness
  -Diffuse weakness
  -Clumsiness
  -Involuntary movements
  -Gait disturbance
  -Urinary or fecal incontinence
  -Dizziness
  -Vision loss
  -Diplopia
  -Dysarthria
  -Dysphagia
  -Acute mental status changes
  -Dementia
  -Aphasia
  -Headache
  -Focal pain
  -Facial pain
  -Neck pain
  -Low back pain
  -Neuropathic pain
  -Numbness or paresthesias
  -Transient or episodic focal symptoms
  -Transient or episodic alteration of consciousness
  -Sleep disorders
  -Developmental disorders

• Approach to Specific Diseases- the evaluation and management of the following neurologic illnesses (either because they are important prototypes, or because they are potentially lifethreatening):
  - Potential emergencies
  • Increased intracranial pressure
  • Toxic-metabolic encephalopathy and acute mental status change
  • Subarachnoid hemorrhage
  • Meningitis/Encephalitis
  • Status epilepticus
  • Acute stroke (ischemic or hemorrhagic)
  • Spinal cord or cauda equina compression
  • Head Trauma
  • Acute respiratory distress due to neuromuscular disease (e.g., myasthenic crisis or acute inflammatory demyelinating polyradiculoneuropathy, a.k.a Guillain-Barre Syndrome )
  • Temporal arteritis
  • Neuroleptic malignant syndrome
  -Amyotrophic Lateral Sclerosis
  -Brain Death
  -Primary and metastatic CNS tumors
  -Coma
  -Dementia (notably Alzheimer’s Disease)
  -Seizures
  -Multiple Sclerosis
  -Myasthenia Gravis
  -Migraine
  -Movement disorders (notably Parkinson’s Disease, essential tremor, tardive dyskinesia)
  -Myopathies (notably polymyositis) and Muscular Dystrophies
  -Cranial Neuropathies (notably Bell’s Palsy and third nerve palsy)
  -Peripheral Neuropathies
  *Acute (e.g. Guillain-Barre Syndrome)
  *Chronic (e.g. diabetic polyneuropathy, carpal tunnel syndrome)

Note: To some extent, the above sections regarding the exam, localization, symptom complexes and specific diseases represent alternative ways of organizing the same subject matter. Some instructors may choose to emphasize some of these approaches more than others. No matter how the clerkship and educational materials are organized, however, all of the topics included in the sections above should be covered in some way.

By the end of the clerkship, the student will be able to recognize the indication for and basic interpretation of ancillary studies including:
-serological studies
-electrophysiological testing
-neuroimaging studies
-neuropsychological testing
-cerebrospinal fluid testing

By the end of the clerkship the student will be able to recognize psychosocial and quality of life issues related to long-term neurological disability.

II. Interpersonal and Communication

By the end of the clerkship, the student will demonstrate the ability to conduct a neurological interview including:

• establish rapport with patients by properly introducing self and defining the role the interview will have in patients' care
• be empathic with patients, showing genuine concern for patients' dilemmas, and viewpoints;
• demonstrate awareness and sensitivity to any gender/cultural/ethnic issues that may impact evaluation and care
• facilitate interviews with helpful blends of open and closed questions, supportive remarks, uses of silences, and therapeutic interruptions
• conclude interviews with proper timing and respect

III. Professionalism

The student will demonstrate professionalism through the ability to:

• be punctual and attend required events
• complete patient notes in a timely fashion with legible writing
• maintain professional boundaries (physical, sexual, financial, and emotional) with patients
• be truthful about medical data
• be courteous to patients, patients' families, staff, colleagues, and other health professionals
• maintain confidentiality regarding patient care
• demonstrate respect, empathy, responsiveness, and concern regardless of the patient's problems, personal characteristics, or cultural background
• demonstrate sensitivity to medical student-patient similarities and differences in gender, ethnic background, sexual orientation, socioeconomic status, educational level, political views, and personality traits.
• demonstrate integrity, responsibility and accountability in the care of assigned patients
• demonstrate scholarship in the form of contributing to a positive learning environment, collaborating with colleagues, and performing self-assessment and self-directed learning to assess one's strengths, weaknesses and health (physical and emotional), and be willing to seek and accept supervision and constructive feedback

Appendix 1: Guidelines for a Comprehensive Neurologic Exam

• Basic Mental Status
  -Level of alertness
  -Language function (fluency, comprehension, repetition, naming and reading)
  -Memory (short-term and long-term)
  -Calculation
  -Visuospatial processing
  -Abstract reasoning

• Cranial Nerves:
  -Vision (visual fields to confrontation, visual acuity, and funduscopic examination)
  -Pupillary reflexes (light, accommodation)
  -Eye movements (including observation for nystagmus)
  -Facial sensation
  -Facial strength (muscles of facial expression and muscles of mastication)
  -Hearing
  -Palatal movement
  -Speech (observation for dysarthria)
  -Head rotation, shoulder elevation
  -Tongue movement

• Motor function
  -Pronator drift
  -Tone (resistance to passive manipulation)
  -Bulk
  -Strength of major muscle groups
  • shoulder abduction, elbow flexion/extension, wrist flexion/extension, finger flexion/extension/abduction, hip flexion/extension, knee flexion/extension, ankle dorsiflexion/plantar flexion

• Sensation
  -Pain, temperature
  -Light touch,
  -Proprioception
  -Vibration
  -Cortical modalities such as graphesthesia and neglect

• Reflexes
  -Deep tendon (biceps, triceps, brachioradialis, patellar, achilles)
  -Plantar responses

• Cerebellar and complex motor function including
  -Finger-to-nose
  -Heel-to-shin
  -Tremor
  -Rapid alternating movements
  -Fine finger movements

• Gait
  -Casual (base, stride, armswing)
  -Heel walk
  -Toe walk
  -Tandem walk
  -Turn

Appendix 2: Guidelines for a Screening Neurologic Examination

All medical students should be able to perform a brief, screening neurologic examination that is sufficient to detect significant neurologic disease even in patients with no neurologic complaints. Although the exact format of such a screening examination may vary, it should contain at least some assessment of mental status, cranial nerves, gait, coordination, strength, reflexes, and sensation. One example of a screening examination is given here.

A. Mental Status (level of alertness, appropriateness of responses, orientation to date and place)

B. Cranial Nerves
1.Visual acuity
2. Pupillary light reflex
3. Eye movements
4. Hearing
5. Facial strength (smile, eye closure)

C. Motor Function
1. Gait (casual, tandem)
2. Coordination (fine finger movements, finger-to-nose)
3. Strength (shoulder abduction, elbow extension, wrist extension, finger abduction, hip flexion, knee flexion, ankle dorsiflexion)

D. Reflexes
1. Deep tendon reflexes (biceps, patellar, Achilles)
2. Plantar responses

E. Sensation (one modality at toes – can be light touch, pain/temperature, or proprioception)

Note: If there is reason to suspect neurologic disease based on the patient’s history or the results of any components of the screening examination, a more complete neurologic examination may be necessary.

Appendix 3: Guidelines for the Neurologic Examination in Patients with Altered Level of Consciousness

A. Mental Status

1. Level of arousal
2. Response to auditory stimuli (including voice)
3. Response to visual stimuli
4. Response to noxious stimuli (applied centrally and to each limb individually)

B. Cranial Nerves

1. Response to visual threat
2. Pupillary light reflex
3. Oculocephalic (doll’s eyes) reflex
4. Vestibulo-ocular (cold caloric) reflex
5. Corneal reflex
6. Gag reflex

C. Motor Function

1. Voluntary movements
2. Reflex withdrawal
3. Spontaneous, involuntary movements
4. Tone (resistance to passive manipulation)

D. Reflexes

1. Deep tendon reflexes
2. Plantar responses

E. Sensation (to noxious stimuli)

Readings/Assignments

All assignments will be based upon the following texts:

• Neurology- An Illustrated Colour Text 2nd Edition (Paperback - Dec 1, 2005). By Geraint Fuller and Mark R.
  Manford.

  This is a required text which should be completed during the course of the clerkship

  Students may choose to purchase this text. In addition, a copy of this book is available at each of
  the medical libraries at the Dayton VAMC, WPAFB, and Children’s hospital, and The Fordham
  Library.

  The following is an approximate timeline for completion of this text

  • 1. Week 1: pp 1-39
    2. Week 2: pp 40-79
    3. Week 3: pp 80-121
    4. Week 4: Review the previous chapters, pp 122-126

• Clinical Neurology, 6th Edition, Copyright © 2005. Michael J. Aminoff, David A. Greenberg, Roger P. Simon.
  This book is available via the online course reserve (see below). The online book does not have page numbers
  and will be assigned the chapter and section names as indicated below.
   
• Articles – At least some of the didactic sessions will required that you read articles as listed below. These are all
  available in the online course reserve under the appropriate topic in the “Useful Articles” section.
   
• Online Course Reserve for the neurology clerkship available on the WSU Libraries Course Reserves site.
  http://www.libraries.wright.edu/

  Log-In: NRL891

  Password: 0809NRL

  Textbooks

  Clinical Neurology, 6th Edition, Copyright © 2005

  Goetz: Textbook of Clinical Neurology, 3rd ed.- In-depth textbook of neurology.
  Excellent illustrations and diagrams.

  Adams and Victor's Principles of Neurology, 8th Edition- Nice section on the
  neurology of normal aging and development

  Journals

  Links to multiple neurology-related journals are available on the website

  Databases

  Links to selected databases with an emphasis on evidence-based medicine and
  instructions to focus upon neurology-related topics

  “Useful Articles”

  We are in the process of generating an online library of articles on various topics in
  neurology that would be useful to medical students. SOME OF THESE ARE
  REQUIRED READING as indicated below.

• Orientation

  Prior to the beginning of the clerkship it is strongly suggested that students review the

  Neurologic exam

  Localization of neurologic lesions

  Suggested reading from at least one of the following texts:

  Neurology- An Illustrated Colour Text 2nd Edition (see above)

  Basic principles pp 1-7

  History and examination pp 8-29

  Weakness pp 58-59

  Numbness and sensory disturbance pp 60-61

  Clinical Neurology, 6th Edition

  Appendix A: The neurologic exam

• Didactic Session One:

  PBL: Movement Disorders (with emphasis on Parkinson’s, Parkinsonism and Tremor)

  Neurology, 2nd Edition - An Illustrated Colour Text:

  Parkinson’s disease and other akinetic rigid syndromes pp 88-91

  Other movement disorders pp 92-93

  Gait, coordination and abnormal movements pp 28-29

  Walking difficulties and clumsiness pp 62-63
   

  Clinical Neurology, 6th Edition:

  Chapter 7: Movement Disorders, entire chapter up to “Sydenham Chorea” section

  Chapter 7: “Drug-induced movement disorders” section

  Chapter 1: Disorders of cognitive function, only the section on “Normal Pressure Hydrocephalous”.
   

  Articles ( under “Movement Disorders”)

  Rao et al. “Does This Patient Have Parkinson Disease?” JAMA 2003;289(3):347-353

  Nutt et al.” Diagnosis and Initial Management of Parkinson’s Disease” N Engl J Med 2005;353:1021-7.

  Louis ED “Essential Tremor”, N Engl J Med, Vol. 345, No. 12

• Core Lecture: Stroke

  Neurology, 2nd Edition - An Illustrated Colour Text:

  Stroke pp 64-69

  Transient ischemic attacks and the prevention of stroke pp 70-71

  Subarachnoid hemorrhage pp 72-73

  Coma and alteration of consciousness pp 50-51

  Disturbances of vision pp 56-57

  Weakness pp 58-59

  Numbness and sensory disturbance pp 60-61

  Clinical Neurology, 6th Edition:

  Chapter 8: Seizures and Syncope, section entitled “Cerebrovascular syncope”

  Chapter 2: Headaches sections entitled “Subarachnoid hemorrhage” and “other cerebrovascular disorders”

• Didactic Session Two:

  PBL: Dementia and Delirium

  Neurology, 2nd Edition - An Illustrated Colour Text:

  Confusion and delirium pp 52-53

  Dementia pp 54-55

  Head injury pp 78-79

  Clinical Neurology, 6th Edition:

  Chapter 1: Disorders of Cognitive Function the following sections

  “Key Concepts”

  “Approach to Diagnosis”

  In “Acute confusional states” the following sections:

  “Nutritional Disorders”

  “Head Trauma”

  In “ Dementia” the following sections

  “Introduction, Approach to Diagnosis, Differential Diagnosis

  “Cerebral Disorders without Extrapyramidal Features

  “Cerebral Disorders with Extrapyramidal Features”

  “Pseudodementia”

  Articles (under “Dementia”)

  Langa et al. “Mixed Dementia: Emerging Concepts and Therapeutic Implications” JAMA 2004;292(23):2901-2908

  Core Lecture: Epilepsy and Seizures

  Neurology, 2nd Edition - An Illustrated Colour Text:

  Blackouts pp 44-45

  Epilepsy pp 74-77

  Neurophysiological investigations pp 32-33

  Clinical Neurology, 6th Edition:

  Chapter 8: Seizures the following sections:

  “Episodic loss of consciousness”

  “Seizures”

  Articles (under “Epilepsy”)

  Chen et al. “Status Epilepticus: Pathophysiology And Management In Adults” Lancet
  Neurol (2006) 5: 246–56

• Didactic Session Three:

  PBL: Multiple Sclerosis and CNS Demyelinating Disorders

  Neurology, 2nd Edition - An Illustrated Colour Text :

  Multiple Sclerosis I

  Multiple Sclerosis II

  Clinical Neurology, 6th Edition:.

  In Chapter 5: Demyelinating Myelopathies

  Articles OPTIONAL (under “Multiple Sclerosis”)

  Courtney et al. “Multiple Sclerosis” Med Clin N Am 2009; 93: 451–476

  Core Lecture: Neuromuscular Disorders and Muscle Disease

  Neurology, 2nd Edition - An Illustrated Colour Text:

  Nerve conduction studies and electromyography pp 34-35

  Radiculopathy pp 82-83

  Peripheral Neuropathies pp 102-105

  Common Peripheral Nerve Lesions pp 106-107

  Disorders of the Motor Neuron pp 108-109

  Disorders of the Neuromuscular Junction pp 110-111

  Muscle Disease pp 112-113

  Clinical Neurology, 6th Edition:

  Chapter 5: “Approach to Diagnosis”

  Chapter 5: “Disorders of peripheral nerves”

  Chapter 5: “Disorders of neuromuscular transmission”

  Chapter 5: in “Myopathic Disorders”: (1) “Inflammatory Myopathies” (2) “Drug-Induced Myopathies”

  Chapter 6: “Approach to Diagnosis”

  Chapter 6: “Peripheral Nerve Lesions”: Introduction

  Chapter 6: in “Polyneuropathies” (1) Idiopathic Inflammatory Neuropathies (2) Metabolic & Nutritional Neuropathies (3) Infective & Granulomatous Neuropathies (4) Drug-Induced & Toxic Neuropathies (5) Hereditary Neuropathies

  Chapter 4: in Disorders of Ocular Motility (4) Diabetic Ophthalmoplegias

Note: the order of the core lecture series will typically be in the same order as above but can vary each month due to lecturer
availability. The actual order will be given out by the clerkship coordinator.

Policies

POLICY ON LEAVE OF ABSENCE

• Only two (2) working days of EXCUSED absences will be allowed.

Only academic (i.e. interviews, academic testing) and medical illness absences will be excused

Absences for other reasons will not be excused and must be made up before the end of the rotation.

More than 2 days of excused absence will require remediation.

Any time off must be cleared with the Clerkship Director as well as the individual preceptors.

• If you will be absent you must notify

Your preceptor's team

Colleen Hayden, the clerkship coordinator, must be informed of all absences and scheduled make up times

POLICY ON HOLIDAYS

• Students should follow the holiday schedule of their preceptors.

Clerkship Sites

Kettering Medical Center
3535 Southern Blvd.
Kettering, Ohio 45429
937-298-3399

Veteran's Affairs Medical Center
4100 W. 3rd Street
Dayton, OH 45428
937-262-2110

Wright Patterson Medical Center
Area A
4881 Sugar Maple Drive
Wright-Patterson AFB, OH 45433
937-257-9655

Children's Medical Center
One Children's Plaza
Dayton, OH 45404
937-641-3080

Private Neurological Practices

Evaluations/Assessments

Final grades are based on the following:

1. Final examination (NBME Shelf) # 40%
2. Preceptor evaluation## 42%
3. Quizzes and Problem Based Learning (PBL) 18%

• NBME Shelf Exam

Passing grade for the shelf is >5th percentile of the previous full academic years data ; 2008-9=60 (NBME raw score)
Students who do not obtain a passing grade will be afforded the opportunity to repeat the exam once at the next available date
Students who retake the exam and pass on the second attempt will be given an overall NBME Shelf exam score of the minimum passing score (i.e., 5th percentile of the previous full academic years data)

## The final preceptor evaluation form is similar in format to that used in the Medicine Clerkship and will be shown during orientation

• Final Grade Grading Scale:

Honors* ≥ 87.5%
Pass ≥ 70%
Fail** < 70%

* Honors ≥ 85th percentile of the previous 2 years’ final numerical grades

**Fail grades: Students who do not obtain a passing grade for the course will be afforded the opportunity to repeat the clerkship.

REQUIREMENTS

• Students are also required to complete the following:

Submit a complete H+P (hand-written or typed)
including complete history, physical, localization, assessment and plan to the preceptor
during the first week of the clerkship.
The student should receive feedback by the second week of the rotation.
There is not a separate grade for this assignment; it is part of the preceptor evaluation
 

• Mid-rotation feedback.

Is required and must be submitted via RMS once completed.
Mid-rotation feedback meetings are to be held between the preceptor and student
The feedback form is to be completed by the preceptor with the student present.
 

• Reading assignments, Quizzes, and Attendance at didactic sessions as detailed on page 6 below
• Final Examination (NBME Shelf)

Please note that students are to be excused from their preceptor sites at 3:00 pm the day before the shelf. It is the student’s responsibility to remind the preceptors of this policy.
 

• Student evaluation of (1) the clerkship and (2) the preceptor.

Both evaluations are required
Students will receive an email notification when the evaluations are ready to be completed through the New Innovations/RMS website.
Note: Final grades for the clerkship will not be released until all evaluations are completed.
 

• Patient logs

Emailed in PDF form from coordinator before beginning of clerkship
Required for completion of this clerkship.
Please return all patient logs to the clerkship coordinator preferably by emailing them to Melinda Henry (melinda.henry@wright.edu). Other options for returning the patient logs are by mail (WSU DOM, 128 E. Apple St., 2nd floor, Dayton, OH 45409) or fax (937-208-2621) in order to receive your final grade.
 

• Return of all pagers, parking permits, etc.,

To each site (if applicable) on the last day of the rotation
Or your final grade will not be released

Lectures

Lecture Schedule: