Neurology Clerkship
4th Year Student

The American Academy of Neurology is encouraging lay people to discuss with their physicians the following twelve neurological symptoms.  Every doctor should know serious implications of these symptoms.  Do you?  No matter what type of doctor you become, family members and patients will confront you with these symptoms, and now is the time to prepare yourselves to help.

Dizziness
Headache
Numbness/Tingling
Memory/Concentration Loss
Blackouts/Seizures
Muscle Weakness/Pain
Unsteadiness
Tremors/Twitches
Head Injury
Sleep Problems
Sudden Vision Change
Slurred Speech

In this clerkship, special emphasis is given to the neurologic emergencies because the conditions are usually very treatable and must be recognized quickly.  Like myocardial infarction, ruptured viscus, and pulmonary embolism, you must be able to recognize neurologic emergencies such as subarachnoid hemorrhage, acute spinal cord compression, stroke and meningitis, to name a few. 

• Introduction and Requirements

• Objectives

• Expectations and Grading
  

• Grade Review Process
  

   

Introduction and Requirements

The structure of the year 4 neurology clerkship will consist of one week on the in-patient service and three weeks in the outpatient clinic.  In addition to the adult neurology clinics those who are interested may request a rotation in pediatric neurology clinic and neurosurgery clinic. You will be required to take one night of call when you are on the inpatient service. Call is taken from home and you will be on call from 4pm until 11pm.

Attendance at morning report at 8am on Mondays, Tuesdays, and Fridays is required.  On Thursdays a combined Neurology/Psychiatry morning report begins at 7:30am.  Details regarding place and time will be e-mailed to you prior to the start of the clerkship.

Case-based discussions and lectures will occur with faculty at the end of the day. 

You will need to see a certain number of patients with specific symptoms and diagnoses that must be documented in your log book.  Also you will need to know about certain other problems.  Please make an appointment with Carolyn Holmes mid-clerkship to review your cases with her. 

You must submit 2 History and Physical Examinations including differential diagnosis, localization of lesion, final diagnosis, and management plan.  

Requests for clerkship absences must be made one month prior to the start of the clerkship.  Please make these requests to Carolyn Holmes.  Urgent requests will be at the discretion of Dr. AbdelSalam.  All clerkship absences will be reported to the Office of Student Affairs. 

Objectives

Nearly 10% of patients seen by family practitioners have neurologic symptoms.  Only 16% of the 45 million Americans who visit a physician for neurologic complaints are ever evaluated by a neurologist.  Primary care physicians are routinely called upon to evaluate and manage patients with neurologic disease.  Therefore, nearly all physicians require a good understanding of the general principles of clinical neurology.  The most suitable setting in which to lay the foundation for that understanding is a neurology clerkship in the clinical phase of medical school.

 

Goals and Objectives of the Clinical Neurology Clerkship

 

Goals: To learn the principles and skills underlying the recognition and management of neurologic diseases that a general practitioner is most likely to encounter in practice, with special emphasis on the neurologic emergencies

 

Objectives:

 

            To learn the following procedural skills:

·     the ability to obtain a complete and reliable history

·     the ability to perform a complete and reliable neurologic examination

·     the ability to deliver a clear, concise, and thorough oral presentation of a patient’s history and examination

·     the ability to prepare a clear, concise and thorough written presentation of a patient’s history and examination

·     (Ideally) the ability to perform a lumbar puncture

 

To learn the following analytical skills:

·     the ability to recognize symptoms that may signify neurologic disease, including disturbances of consciousness, cognition, language, vision, hearing, equilibrium, motor function, somatic sensation, and autonomic function

·     the ability to localize the likely site or sites in the nervous system where a lesion could produce a patient’s symptoms and signs

·     the ability to formulate a differential diagnosis based on lesion localization, time course, and relevant historical and demographic features

·     an awareness of how to use and interpret common tests used in diagnosing neurologic disease

·     an awareness of the principles underlying a systematic approach to the management of common neurologic diseases, including the recognition and management of situations that are potential emergencies.

 

Content of subjects to be taught

 

A.     The neurologic examination (as an integral component of the general medical examination)

1.      how to perform a complete neurologic examination

2.      how to perform a screening neurologic examination

3.      how to recognize and interpret abnormal findings on the neurologic examination

 

B.     Localization – general principles differentiating lesions at the following levels:

1.      cerebral hemisphere

2.      posterior fossa

3.      spinal cord

4.      nerve root/plexus

5.      peripheral nerve (mononeuropathy, polyneuropathy, and mononeuropathy multiplex)

6.      neuromuscular junction

7.      muscle

 

C.     Disease Management – general principles governing (urgent and non-urgent) evaluation and management of:

1.      acute mental status changes

2.      strokes

3.      seizures

4.      chronic mental status changes

5.      headaches and facial pain

6.      low back pain

7.      neck pain

8.      peripheral neuropathies (especially subacute toxic and metabolic neuropathies and Guillain-Barre syndrome)

9.      cranial neuropathies (notably Bell’s palsy, third nerve palsy)

10.  common movement disorders (notably Parkinson disease, essential tremor, tardive dyskinesia)

11.  meningitis and encephalitis

12.  multiple sclerosis

13.  myasthenia gravis

14.  polymyositis

15.  primary and metastatic CNS tumors

16.  sleep disorders (notably obstructive sleep apnea, narcolepsy)

17.  developmental delay and developmental regression

 

D.     Identify the following normal anatomy on a CT or MR scan

1.   frontal, parietal, temporal and occipital lobes

2.   sylvian fissure

3.   caudate and putamen

4.   globus pallidus

5.   substantia nigra

6.   thalamus

7.   pituitary gland

8.   cerebellum and cerebellar peduncles

9.   midbrain, pons and medulla

10. lateral, third and fourth ventricles and the cerebral aqueduct

11. corpus callosum

12. spinal cord

13. intervertebral disc and nerve root

14. cauda equina

 

E.     Identify the following types of pathology on a CT scan or MR scan

1.   subarachnoid hemorrhage

2.   intracerebral hematoma

3.   brain abscess

4.   infarct (hemorrhagic vs bland)

5.   glioma, meningioma and metastatic brain tumor

6.   subdural and epidural hemorrhage

7.   Arnold-Chiari malformation

8.   hydrocephalus

9.   multiple sclerosis

10. herniated intervertebral disk

11. cerebral edema

 

F.   Identify the following normal anatomy on a conventional cerebral angiogram or MR angiogram.

1.   common, internal and external carotid arteries

2.   vertebral and basilar arteries

3.   anterior, middle and posterior cerebral arteries

 

G.     Using angiography, recognize

1.   atherosclerotic stenosis and occlusion of a major vessel

2.   arteriovenous malformation

3.   cerebral aneurysm

Expectations and Grading

1.      Satisfactory clinical performance on the inpatient service and in the
   clinics.

2.      Satisfactory completion of two written History and Physical
   Examinations.

3.      Logbook requirements completed satisfactorily.

4.      A passing grade on the homework assignments.

5.      Students must take the NBME and receive a score of at least in the
   10^th percentile.

6.      Satisfactory performance on the final patient examination and OSCE’s.

7.      Prompt attendance and satisfactory professional behavior.

 Grading

    1.      Clinical Performance – 30%

     2.       NBME – 30%

     3.       Patient exam and OSCE’s – 20%

     4.       History and Physicals – 10%

     5.       Homework Assignments – 10%