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 of Neurology Clerkship
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 10pm.

Case-based discussions and lectures will occur with faculty between 8-9am.  The schedule will be sent to you before you begin clerkship.

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 at least ONE History and Physical Examinations including differential diagnosis, localization of lesion, final diagnosis, and management plan. This will be reviewed by the clerkship director and he will give you feed back.  
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. Harirama K. Acharya.  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

To learn the following analytical skills:

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.      peripheral neuropathies (especially subacute toxic and metabolic neuropathies and Guillain-Barre syndrome)
8.      cranial neuropathies (notably Bell’s palsy, third nerve palsy)
9.  common movement disorders (notably Parkinson disease, essential tremor, tardive dyskinesia)
10.  meningitis and encephalitis
11.  multiple sclerosis
12.  myasthenia gravis
13.  polymyositis
14.  primary and metastatic CNS tumors
15.  sleep disorders (notably obstructive sleep apnea, narcolepsy)
16.  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 one written History and Physical Examinations with minimum score of 60%.
3.  Logbook requirements completed satisfactorily.
4.  Students must take the NBME at the end of the clerkship and receive a score of at least a score of 60.
6.  Satisfactory grade in Clinical Skills Evaluation.
7.  Prompt attendance and satisfactory professional behavior.

Grading
1.  Clinical Performance – 30%
2.  NBME – 30%
3.  Clinical skills evaluation – 30%
4.  History and Physicals – 10%

 

Honors:

• Attendance at all outpatient clinics and in patient service rotation
• Attendance and participation and all faculty case conferences
• History and Physical Examination documentation score of > 80%
• NBME Examination score of 80 and above
• Excellent grade in Clinical performance evaluation
• Excellent grade in Clinical Skills Evaluation.