NEUROLOGY CLERKSHIP MANUAL & SURVIVAL GUIDE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE Rob Naismith M!D! C"#$%shi Di$#'to$
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THE CENTRAL AXIOM............................................................................................. ERROR! BOOKMARK NOT DEFINED. WHAT MAKES NEUROLOGY DIFFERENT............................................................. ERROR! BOOKMARK NOT DEFINED. DISPELLING DISPELLING SOME MYTHS................. MYTHS............................... ........................... .................................................... ....................................... ERROR! BOOKMARK NOT DEFINED. NEUROLOGY CLERKSHIP GOALS AND OBJECTIVES......................................... ERROR! BOOKMARK NOT DEFINED. NEUROLOGY CLERKSHIP REQUIREMENTS AND EXPECTATIONS................... ERROR! BOOKMARK NOT DEFINED. FIRST DAY, CALL, AND DAYS OFF...................................................................................................................................... GRADING............. GRADING........................... ........................... ........................... ........................... ........................... ............................ ........................... ........................... ............................ ........................... ........................... ....................... .........
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TEAMS AND PRESENT PRESENTATIONS.................. TIONS................................ ........................... ........................... ............................ ........................... ........................... ............................ ................................... ..................... .. 11 PATIENT LOGS...................... LOGS................................... ........................... ........................... ........................... ............................ ........................... ........................... ............................ ........................... ................................ ...................
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TEXTBOOKS...... TEXTBOOKS.................... ............................ ........................... ........................... ............................ ........................... ........................... ........................... ........................... ................................................... .....................................
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PRE!PRINTED PRE!PRINTED H"P FORMS................ FORMS.............................. ........................... ........................... ............................ ........................... ........................... ............................ ........................... .............................. ................. 1# DRESS............... DRESS............................. ............................ ........................... ........................... ............................ ........................... ........................... ............................ ........................... ........................... ...................................... ........................
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COMPUTER COMPUTER ACCESS............. ACCESS........................... ............................ ........................... ........................... ............................ ........................... ........................... ........................... ........................................... ..............................
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CLINICS............... CLINICS............................. ........................... ........................... ............................ ........................... ........................... ............................ ........................... ........................... ........................... .................................... .......................
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CONFERENCES.... CONFERENCES.................. ........................... ........................... ............................ ........................... ........................... ........................... ........................... ............................ ........................... .................................. .....................
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ROTA ROTATION DESCRIPTIONS DESCRIPTIONS AND REQUIREMENTS..... REQUIREMENTS................... ............................ ........................... ........................... ............................ ........................................ .......................... .... 1% INPATIENT ADULT NEUROLOGY...................................................................................................................................... NEUROSURGERY NEUROSURGERY............. ........................... ............................ ........................... ........................... ............................ ........................... ........................... ........................... ........................... ............................ ...................... ........ PEDIATRIC NEUROLOGY CONSULTS.............................................................................................................................. WEEKLY GENERAL NEUROLOGY CLINICS.....................................................................................................................
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SURVIVAL GUIDE FOR THE NEUROLOGY CLERKSHIP................................................................................................. % THE NEUROLOGICAL HISTORY........................... ......................................... ............................ ........................... ........................... ........................... ........................... ............................ ........................... ..................... ........ THE NEUROLOGICAL EXAM.......................... ........................................ ........................... ........................... ............................ ........................... ........................... ........................... ........................................ ........................... WRITE!UPS........................... ......................................... ........................... ........................... ............................ ........................... ........................... ............................ ........................... ........................... ................................... ..................... PRESENTATIONS.......................... ........................................ ........................... ........................... ............................ ........................... ........................... ........................... ........................... ........................................... .............................
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NEUROLOGICAL NEUROLOGICAL DIAGNOSIS......... DIAGNOSIS....................... ............................ ........................... ........................... ........................... ........................... ............................ ........................... .................................. ..................... #1 THE NEUROLOGICAL NEUROLOGICAL WRITE!UP.............. WRITE!UP............................ ........................... ........................... ............................ ........................... ........................... ........................... ..................................... ........................ ($ CHIEF COMPLAINT .......................... ........................................ ............................ ........................... ........................... ........................... ........................... ............................ ........................... ....................................... .......................... HPI.................... HPI................................. ........................... ........................... ........................... ............................ ........................... ........................... ............................ ........................... ........................... ........................................ .......................... OCUMENTING THE REST OF THE HISTORY D )....................... )..................................... ........................... ........................... ............................ ........................... ........................... ............................ .................... ...... EXAM.......................... ........................................ ........................... ........................... ........................... ........................... ............................ ........................... ........................... ............................ ........................... ............................... .................. ASSESSMENT AND PLAN.......................... ........................................ ............................ ........................... ........................... ............................ ........................... ........................... ............................................ .............................. FORMATTING ISSUES ......................... ....................................... ............................ ........................... ........................... ............................ ........................... ........................... ........................... ........................... ........................ ..........
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STEP!BY!STEP GUIDE TO THE NEUROLOGICAL EXAMINATION.................................................................................. &0 SAMPLE NEUROLOGICAL NEUROLOGICAL H " P........................ P..................................... ........................... ............................ ........................... ........................... ............................ .......................................... ............................ &' MID ROTATION ROTATION FEEDBACK FORM******************** FORM********************************... ************... *****************$# NEUROLOGICAL NEUROLOGICAL EXAM FEEDBACK FEEDBACK FORM.................... FORM.................................. ........................... ........................... ........................... ........................... ........................................... ............................. $$ STUDENT SELF ASSESSMENT ASSES SMENT FORM****************.******************..$$ FORM****************.******************..$$ NEUROLOGY CLERKSHIP EVALUATION EVALUATION FORM.................. FORM........ ..................... ...................... ..................... ..................... ...................... ..................... ..................... ...................... ........... ...... ..... . $8
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ORIENTATION FOR NEUROLOGY CLERKSHIP Welcome to your Neurology Clerkship. Please read this manual before orientation. t !ill also help clarify your first fe! days of the rotation" !hich can be the most confusing and stressful days. The Central Ax"
#$erything you ha$e !orked for has been for this moment. %he brain lies at the center of our personal uni$erse. t transforms a chaotic !orld of hurling particles into the perception of sense and stability. n addition to creating a sensory representation of reality" the brain also allo!s us to be a!are of oursel$es and others. #$ery #$ery ner$ous ner$ous sys system tem proces processs can be decons deconstru tructe cted d into into sensat sensation ion"" mo$ mo$eme ement" nt" emotio emotion" n" memory memory"" and communication. %he brain allo!s humans to create" e&plore" interact" and yearn for something better. t contains our greatest dreams and hopes" as !ell as our fears and nightmares. t is !here life and religion originate. t is !here good and e$il reside. t is !here life ends. %he central a&iom of medicine is simple. Support and protect the brain. #$erything you ha$e learned in medical school has directly or indirectly been for this purpose. %he %C' cycle" ( proteins" anatomy of the heart" acid)base balance and the kidney" and o&ygen transport !ith the blood and lungs are all critical to keep the brain ali$e. *o not misinterpret this to mean that e$eryone should become a Neurologist. %hat !ould be foolish" and not in the brain+s best interest. We need cardiologists" nephrologists" and pulmonologists. n the game of chess" the pa!ns are important as !ell. f e$ery piece !as the king" then chaos !ould reign. ,ust as the body has di$ided the organs to protect and support the brain" so must the field of medicine emulate this di$ision of labor for the greater good. -o rest assured. %he goal of this clerkship is not to transform e$ery medical student into a Neurologist. #h$ Sh%l& #e St%&$ the Bran
/earts and kidneys are %inkertoys0 +m talking about the central ner$ous system. (ene Wilder" 3oung 4rankenstein 4ranke nstein %he brain is by far the most comple& c omple& and fascinating organ of the body. 'lthough 'lthough some may try to argue" it is the organ most !orthy of a lifetime of study. %he brain can be contrasted co ntrasted !ith the heart" !hich undoubtedly plays a key supporti$e role. %he heart" in all its intricacy" intricacy" comes do!n to chambers" $al$es" and some electrical !ire. f note is that it can also be replaced" by a manmade rendition. %he heart of one person can be transplanted into another person !ithin a matter of hours. hou rs. No!" No!" ho! complicated can that be7 b e7 %here remains much to be kno!n about the brain. 'lthough tremendous strides are made each year" the study of the brain remains in its infancy. %his black bo& is intimidating for many medical students" but has also been the source of fascination for the !orld+s !orld+s greatest scientists" !riters" and philosophers. t+s t+s true that you cannot measure pressure or $olume or electrical conductance for the brain as you can !ith the heart. 's 8uoted by #merson Pugh9 f the human brain !ere so simple %hat !e could understand it" We !ould be so simple %hat !e couldn:t. #hat Ma'e( Ne%rl)$ D**erent
's you make your !ay through your clerkships" you !ill note that each field has a particular approach to patients" and also tends to attract a certain personality. 3ou !ill find most neurologists are both curious and content. Primary importance continues to be placed upon a proper history in order to arri$e at the correct diagnosis diagnosis and course of action. 'lthough 'lthough there are pressures pressures upon e$eryone e$eryone in medicine to see more patients" patients" the initial e$aluation cannot be shortrift. n clinic" a ne! patient $isit can take an hour" and a follo!up can take ;< minutes. 4or a complicated ne! patient in the hospital !ith an acute problem" it may take !ell o$er an hour to do the initial assessment. We learn medicine by talking !ith patients. %e&tbooks ser$e as a guide" but patients translate the medical terminology into the human e&perience. No one is an e&pert by reading a book chapter and seeing a single person !ith a gi$en condition. t !ill take many patients !ith a gi$en condition and follo!ed o$er years V6.15.11
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until you begin to reali=e ho! a disease presents and affects someone. %he contact !ith your patients is in$aluable and needs to be fully appreciated. f you kno! ho! to listen and make obser$ations" it !ill enrich your practice and the rest of your life. ' good history takes time. $er se$eral years" you !ill learn to ask openended and nonleading 8uestions. Neurologists from a pre$ious generation !ould say that you get nothing meaningful in the history during the 1st half hour0 >nfortunately" there are some time constraints" so most histories should be completed in 2<;< minutes unless they are complicated. 's you obtain the history" you start to form a hypothesis about !hat is going on. 'dditional 8uestions !ill further test your hypothesis and de$elop concepts relating to locali=ation. 3ou !ill then ask additional 8uestions to help refine your locali=ation. %he history is a dynamic process that does re8uire some skill and e&perience. 3ou need to be fle&ible to get the information" and you need to scrutini=e that information for further clarification to help !ith medical decision making. 3ou also need the kno! ho! to phrase each open ended 8uestion so that the patient !ill pro$ide a description in their o!n !ords. Computers can ask 8uestions" physicians elicit a history. t is also crucial to understand something about the patient+s en$ironment" and ho! their illness has impacted their ability to function. %he physical e&am is also a dynamic process. #$ery patient !ill get a complete e&amination" but you need to be fle&ible and scientific as !ell. 3ou !ill carefully scrutini=e key parts to test your hypotheses and con$ince yourself !hether a sign is truly present or absent. f you are unsure" you need to repeat the e&am maneu$er until you are sure. 'n 'ttending can spend either 1< seconds on the refle&es or 5 minutes" depending upon the clinical scenario. %his need to think onyourfeet becomes $ery en?oyable once comfortable !ith the concept. n addition to talking" Neurologists like to e&amine patients. %he neurological e&am is $ery important and ser$es many purposes. @ost patients" unless they ha$e headaches or sei=ures" !ill ha$e many interesting neurological findings. f you come to mo$ement disorders or multiple sclerosis clinic" then almost e$eryone has an abnormal physical e&am. %he e&am can take a substantial part of the office $isit. -ince you spend time touching the patient" it also helps to solidify the physicianpatient relationship. -ome medical specialties see the e&am as a necessary formality that doesn+t yield much useful information. %his is not so for Neurology" and is an ine&tricable component of a proper assessment. %he neuro e&am !ill not often gi$e you an ans!er as to the diagnosis" because the findings are typically not that specific. /o!e$er" it !ill gi$e you an idea as to !here to locali=e" ho! much the person is functionally affected" and also a differential diagnosis. ne can really appreciate ho! people ha$e difficulties in their e$eryday li$es by e&amining them. -ome may find it frustrating that most neurological diseases do not ha$e a laboratory test that gi$es a Ayes+ or Ano+ ans!er. Parkinson+s disease is based solely upon the clinical characteristics of a unilateral tremor !ith bradykinesia" rigidity" and postural instability. *espite strides in neurodiagnostic testing" it also remains true that migraines" epilepsy" @.-." and stroke remain a diagnosis based on predominantly on clinical grounds. t is not like doing a cardiac catheteri=ation to determine if they ha$e coronary disease. Neurologists kno! ho! to spend money on tests" this is for sure. /o!e$er" a test !ithout the proper reasoning !ill often create more confusion than illumination. 4inally" neurologists tend to en?oy talking about their specialty. -ince the brain is so interesting" it is hard not to teach and discuss. Patient rounds can be long" but hopefully you !ill find them both educational and en?oyable. Bounds are your opportunity to obser$e the e&perienced attending" !ho has been doing this for some years. asically" e$erything the attending says and does !ith the patient is for a particular reason. %here is a lot of learning that can be accomplished on rounds" e$en though it may not seem like there is specific Ateaching+. D(+elln) S"e M$th(
Neurology is depressing. >ntrue. %he first reason for this misconception is that 2 nd year medical school courses are often taught based upon pathology. While our Pathologists do a !onderful ?ob at e&plaining the basis and the structural changes associated !ith neurologic diseases" pathology is biased to those patients !ho did not do !ell. What you learn about are the large strokes that herniated and died. 'nd the /-V#ncephalitis that herniated and died. 'nd the endstage 'l=heimer+s that aspirated and died. -econd" medical school clerkships are often based on inpatient e&periences. %here is no doubt that inpatient neurology contains its fair share of neurological catastrophes. ut that e&perience should not be V6.15.11
construed as typical. When you go to outpatient clinic" you !ill notice strokes and @- and headaches and epilepsy and Parkinson+s disease" !ith people !ho are doing remarkably !ell. %hird" e$en some of the neurological catastrophes do remarkably !ell. 3ou are seeing these patients in their darkest hour. %hey are comatose" paraly=ed" cannot speak or understand. 3ou don+t al!ays get to see them in 6 or 12 months. 4or many" reco$ery can be remarkable. 4inally" this all needs to be placed into perspecti$e. >nless you are doing !ell$isits in family practice" e$ery field in medicine has its depressing side. Pediatric oncology can also be depressing. @any people !ith heart and lung and kidney disease are se$erely disabled and not doing !ell. -ometimes !e mistake our impression of control and our ability to prescribe modest therapies as e8ui$alent to being effecti$e. Diagnose, then adios. 'gain" false. %he charge is t!ofold9 that Neurologists are only interested in the processes of locali=ation and diagnosis" and that there are no treatments. 's the ?oke goes" the neurologic therapeutic arsenal contains phenytoin" steroids" and heparin. 4irst" you need to understand that your po!er as a doctor is not ?ust because you can prescribe medications. Distening to patients is the most important thing you can do" and it can be $ery therapeutic. Patients can discuss their innermost concerns !ithout fear of reprisal or ?udgment. 'nd they can discuss their $aried symptoms !ith someone !ho understands them. @any people feel uncomfortable telling this stuff e$en to their spouse" family" or close friends. -ome !orry that they are cra=y or that their e&perience is uni8ue. Con$eying their e&perience can be cathartic. -econd" neurology does ha$e many therapeutic agents. Whether it is @- or epilepsy or headache or mo$ement disorders" there has been tremendous de$elopment of effecti$e medicines. %hird" !hat !e can do for our patients is not limited to supporting the pharmaceutical company. We teach and pro$ide information. We ser$e as a liaison for support groups. We coordinate multidisciplinary teams for dealing !ith serious illness. Behabilitation medicine stri$es to keep people ambulating" mobile" !orking" and doing all those other things in their life !hich they care about. We can offer clinical trials that may help the patient" and !ill hopefully lead to ne! therapeutic options. Neurology is too complicated. Wrong. %he first !eek of the rotation might be a bit intimidating. et!een remembering your neurosciences" neuroanatomy" diseases of the ner$ous system courses" locali=ing the lesion" and prioriti=ing a differential diagnosis" there is definitely much information to consider. /o!e$er" !ithin a !eek" you !ill be doing all these things. y the end of the !eeks" you should ha$e a $ery good appreciation of ho! to recogni=e and communicate neurological issues to other physicians. The MRI will replace Neurologists. 3eah. Bight. %hey+$e been saying this since the first head C% scanner !as created in the AE
ntil that happens" you are al!ays !elcome back for another month in your final year.
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Ne%rl)$ Cler'(h+ Gal( an& O,-et/e( Proficiency in
obtaining a complete history in patients !ith the follo!ing neurological complaints9 *isorders of consciousness @ental status and)or beha$ioral changes @emory complaints Pain in the head" neck" and back Numbness" paresthesias" and neuropathic pain Weakness and clumsiness *i==iness and $ertigo *isorders of language Neurogenic bladder and bo!el Vision loss and diplopia *ysarthria and dysphagia 'bnormal mo$ements -leeprelated complaints
>nderstand the pathophysiology and treatments for
the follo!ing neurological conditions9
schemic
stroke /emorrhagic stroke -ubarachnoid hemorrhage -ubdural and epidural hemorrhage -tructural coma @etabolic encephalopathies Neuroto&icology and $itamin deficiencies @eningitis and encephalitis *ementia and memory disorders -ei=ures and epilepsy Fincluding status epilepticusG -yncope Vertigo /eadache disorders F@igraine" cluster" tension" analgesiao$eruse" neuralgiasG Neck and back pain @yelopathies Badiculopathies Fincluding cauda e8uina syndromeG Ner$e compression Neuropathies @ultiple -clerosis and other immunologic diseases Fsarcoid" -D#" paraneoplastic disordersG @o$ement disorders FParkinson+s disease" essential tremor" /untington+s disease" tics" medicationinduced dyskinesiasG Neuromuscular disorders F@yasthenia" (-" Dambert#aton" botulismG @yopathies rain tumors /ead trauma Comfort
!ith the neurological e&amination" so that you could communicate medical problems to a neurologist regardless of your chosen field. Complete neurological e&am 4ocused neurological e&am Coma e&am Docali=ation based upon the history and e&amination >nderstand
the neurological tests that are a$ailable and !hat purpose they ser$e9 @B" including a basic understanding of reading. Dumbar puncture
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C%" including a basic understanding of reading. ##( Ner$e conduction studies )
#lectromyography
#$oked potentials @yelogram -leep
studies
*emonstrate
a commitment for reading about your patients and lifelong learning Core reading throughout the clerkship Beading indepth about your patients 'bility to discuss pertinent topics on rounds Concepts of #$idenceased @edicine
'bility
to put your patients at ease and establish an effecti$e relationship. %ake a complete history !ith openended nonleading 8uestions. >nderstanding the disease in the conte&t of a person+s life and the !ay it affects them. Professional and empathetic first encounter -peaking !ith families Heeping your patients informed about upcoming tests and treatment plans -ee ho! residents and attendings hold family discussions and deli$er bad ne!s
Communicate effecti$ely and efficiently to other
physicians and health care members regarding patients. nformal and formal patient presentations nitial /IP Notes Progress and 4ollo!up Notes Coordinating disposition !ith P%" %" -%" -ocial !ork" and Case manager Writing orders" discharge papers" and prescriptions
*emonstrate
a mature and professional demeanor to patients" peers" r esidents" and attendings. Presentation skills Participation in discussion during rounds and conferences %aking o!nership of your patients nterest and learning from other patients you are not directly follo!ing Paying attention during rounds
>nderstand the reasons
for patient admissions" consults" transfers" disposition" and follo!up appointments. /o! to decide on !hether to admit a patient" and to !hich ser$ice they should be admitted to When to transfer someone to another ser$ice or to the C> When to call and not to call a consult Beasons for discharge to home Fincluding appropriateness of homebased ser$icesG" rehab" skilled nursing)e&tended care facility" and longterm nursing facility . '!areness of social" ethical" and pri$acy issues !ithin medicine. /P'' Communication nsurability #conomics of health care Besearch Confidentiality 'ltruism" beneficence" autonomy" paternalism" duty" rights" e8uality" ?ustice" liberty" nonmaleficence 'd$anced directi$es Vegetati$e states
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Ne%rl)$ Cler'(h+ Re0%re"ent( an& Ex+etatn( Preround on your patients. e a!are of the results for all tests" consultant notes" problems o$ernight" etc. Pickup at least t!o patients on calldays" one patient on a noncall admitting day. F@ay $ary according to censusG When on call" be a$ailable all night to !orkup patients and assist your resident. e !ellprepared to present your patients precisely and completely during rounds" including locali=ation" prioriti=ed differential" and your plan. Pay attention to !hat is happening on rounds. #$erything the attending says and does is for a reason. Participate in discussion on rounds and in conferences. Heep your patients informed" checkin !ith them at the end of the day. Politely e&cuse yourself !hen you ha$e to lea$e for a re8uired teaching session. /a$e your /IP in the chart on the day of admission" before morning rounds if admitted o$ernight. /a$e your notes complete and ready to be e$aluated by your resident by appro&imately noon. Write orders" help coordinate disposition and follo!up. Be8uest critical feedback from your resident in the second !eek of your rotation. Bespond to deficiencies !ith a plan for impro$ement. /a$e your resident !itness your physical e&am on a patient" and fillout your sheet. Come to conferences prepared and ready for discussion. /and back feedback forms preferably by the 2 nd !eek" and no later than the ; rd !eek. %his includes midterm feedback" !itnessed e&am" /IP. /and in your patient and re8uired circumstance logs at the end of the clerkship. @ichelle 'ubuchon can collect these" and she is on the ;rd floor. e proacti$e about seeing patients and creating learning opportunities.
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Fr(t Da$1 Call1 an& Da$( O** (EGIN PATIENT CARE ON DAY ONE. 'fter you meet !ith your resident to re$ie! e&pectations and procedures" run the patient list and ask !hich patients you should begin to follo!. 'll patients !hose !orkup is ongoing should be di$ided among the students on the team. f these patients ha$e already been presented on rounds" you need not do an initial /IP. Bather perform a thorough chart re$ie! and meet !ith each patient to re$ie! their history and physical e&am so you !ill ha$e a firsthand understanding of their situation. /elp !ith a progress note and any coordination of care for that day. %he ne&t day" preround" update the team on rounds" and assist !ith their medical care. t is absolutely critical that you become $ery in$ol$ed in patient care on day 1 " because the adult inpatient rotation is so short0 3ou must not !ait until your call day to recei$e patients. -hortcalls are admissions" transfers" or handoffs that occur bet!een E'@5P@. 3ou should pickup at least 1 shortcall patient !hene$er your resident recei$es such a patient. f a short comes during the morning" and you ha$e conference and clinic" then you need to return after clinic to finish the !orkup and get the note in the chart. 3ou should pickup at least 2 patients !hile oncall. 3ou should ta%# th# )i$st * a+ai"ab"# ati#,ts o, -o.$ 'a"" /a-. *o not !ait for the perfect patient. 3ou !ill take both general neurology and stroke patients !hen oncall. 3ou should also !orkup patients from faculty members F!ho may not be presented on roundsG. 3our resident !ill play a crucial role in the grading process" so !orkingup a patient !ho may not necessarily be presented on morning rounds !ill definitely count to!ards your clinical assessment. O.t o) a 01/a- s'h#/."# o, a/."t i,ati#,t -o.$ 2oa" is to 3o$%1. a mi,im.m o) 4 ,#3 ati#,ts 3ith )."" H&Ps! Yo.$ 'a"" /a- 3i"" b#2i, 3ith $o.,/s that /a- . While your assigned resident !ill start at 5pm" you should prepare for rounds and help pro$ide continuity. Postcall" you are done at 1pm if there is a re8uired student conference" or noon if there is not a re8uired student conference. 3ou are e&cused from postcall conferences after 1pm. 3ou are not to be in the hospital for o$er ;< hours on your call day. 3our resident !ill stay the remainder of the day to complete the patient care !ithout your assistance because they started their call time later than yours. When you return on the morning of your postpostcall day" be sure to update yourself before rounds on !hat transpired on your patients the pre$ious afternoon. f something significant happened that you don+t kno! about" it !ill not look good on rounds that you are out of the loop. #$eryone !ill ha$e at least 5 days off o$er the rotation. %hese !ill be specified on the schedule. #$eryone !ill ha$e the same number of calls F2G. Besidents are on call e$ery 6 th e$ening. %he residents ha$e hours off each !eek" !hich includes their precall day" and ends !hen they start call at 5 pm. ecause !e are desynchroni=ing the student)resident schedule" you !ill need to spend time !orking !ith another resident on your assigned resident+s day off. When your resident is off" first check !ith the floor chief resident to see if there are any particular patients you should follo!" or particular teams you should assist. %he chief resident may kno! of an interesting patient that does not yet ha$e a student. %he busiest team on the ser$ice is usually the postcall team" follo!ed by the postpostcall team. 3our ?ob is to pro$ide continuity for your team+s group of patients that day" and to assist one of the busier other teams. f your first day coincides !ith your residents dayoff" then re$ie! the charts and patients from that team" and help !ith the progress notes. f you are finishing inpatient adult during the 1 st half of the rotation" you !ill be done 4riday e$ening unless you are on call riday . f you are finishing call on 4riday" then you stay through rounds on -aturday" -unday is a day off" and you start the ne&t half on @onday. f you are starting inpatient adult ser$ice during the 2 nd half of the rotation" you !ill b#2i, o, th# 3##%#,/ 5Sat.$/a-6. -omeone !ill take call on 4riday starting at 5pm. ecause the 2 nd half is shorter due to the -C# and !ritten e&am" !e need to start 4riday e$ening so no one needs to take a test postcall. 3ou should still be on consults 4riday during the day if you are oncall that e$ening for your s!itch. 4or the student taking call the 1 st 4riday of the 2 nd half" you may be o$erlapping !ith the student finishing their last call" !hich is not bad for continuity and orientation. %here are se$eral options for call rooms. %he first is the m ain call room area on 11<<. %here are 2 rooms" one for the oncall resident" and another room !hich may be a$ailable. %here are also call rooms behind ;21 Band ,ohnson. %he ;2 call suite has t!o entrances on its north side. n the corridor bet!een these doors" there is a brasscolored drinking fountain. 'cross the hall from this fountain is an unmarked door !ith a card reader. %his is the !estern entrance to ;21" and the medical student call rooms are ?ust inside that door. %he call rooms are accessed by card s!ipe. 'lso let us kno! !hether your card does not !ork" because there ha$e occasionally been delays in ha$ing this acti$ated. /ere+s a pearl of !isdom on being postcall. 3ou !ill feel much less tired if you take a fe! minutes to sho!er" dry your hair" and change into fresh clothes. #$eryone else !ill appreciate it as !ell. %aking a fe! minutes for breakfast is also !orth!hile. Coffee helps" too. %he combination of all these things is probably e8ui$alent to 2; hours sleep. 3ou are done !ith your clinical rotation at 1pm on the final %hursday. f you are going to be absent for !hate$er reason" you need to inform your -uper$ising Besident and the Clerkship *irector immediately. f you are sick for more than 2 days" !e !ill need a note from student health. We follo! the absence policy in the online ulletin of W>-@ 'dmissions and #ducational Program (uide.
D%t$ H%r Pl$ *r Me&al St%&ent( V6.15.11
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%he Neurology Clerkship follo!s the Washington >ni$ersity duty hour policy for medical students. %his policy is similar to !hat the 'C(@# has instituted for residents. f your Neurology Clerkship e&perience is not consistent !ith this policy" please let *r. Naismith kno!. %he policy is9 1G -tudents must not ha$e more than J< clinical duty hours during a E day !eek" a$eraged o$er a !eek period. 2G -tudents must ha$e four 2hour periods off o$er four !eeks. ;G -tudents must not be on o$ernight call more than e$ery third night. G -tudents cannot be on call for more than 2 successi$e hours" !ith an added period of up to 6 hours for continuity" educational debriefing" and didactic acti$ities. No ne! patients should be assigned to students after 2 hours. 5G 4or a W> holiday" students are dismissed at 5pm the day prior" and return the day follo!ing the holiday. 6G Planned daysoff need to be cleared !ell in ad$ance !ith the clerkship director" and shall follo! the absence policy for Clerkships. @akeup days !ill likely be re8uired for any time off. %he resident and the rest of the team need to be informed if you are not coming for any planned or unplanned reasons.
Gra&n) take my responsibility to o$ersee the grading process $ery seriously. still appreciate ho! important grading is for e$eryone. We actually en?oy gi$ing honors. When !e gi$e honors" e$eryone feels good. /o!e$er" !e don+t !ant to tri$iali=e this highest achie$ement. Nonetheless" if e$ery student during the clerkship does honorsle$el !ork" then e$ery student !ill get honors since there are no 8uotas. 3ou are not in competition !ith your fello! classmates. ased upon past e&perience" roughly ;-@ performance" !hich is e&cellent. 'bout 5n8uenchable thirst for selfdirected kno!ledge. >ses scientific medical literature to discuss patient care. Hno!s !hen to ask intelligent 8uestions" and !hen to look it up themsel$es. ;G >nderstands their role on the team. Proacti$ely identifies !hat needs to be done !ithout o$erstepping their bounds" becoming obtrusi$e to the residents" or abrasi$e to their fello! students. G *isplays tremendous respect and dedication for their patients. -he)he ensures their comfort and pri$acy" speaks !ith them before lea$ing for the day to discuss test results and plan for the ne&t day" and is a$ailable to meet !ith the family under their residents+ super$ision. 5G (ets the !ork done thoroughly" efficiently" and reasonable independence. 6G Besponds to feedback" displays marked selfimpro$ement" stri$es to do the best ?ob possible. EG *isplays respect for their colleagues" residents" and attendings. >nderstands there is something to learn from e$eryone. JG *oes not complain or critici=e. KG /istories are complete and accurate" !ith crucial details to pro$ide best medical care. 1
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2G %rouble presenting patients by reading from the note" the history and e&am could be disorgani=ed" or they may not be able to establish a cogent diagnosis and plan. ;G /istory is incomplete and superficial. *oes not re$ie! background information or speak to additional informants. G Needs continuous direction on !hat to do ne&t. %asks not al!ays accomplished. Besidents may not find reliable. 5G *oes not impro$e sufficiently o$er the !eeks. -lo! to respond to feedback. @ay repeats mistakes in the ; rd and th !eek as done in the 1 st !eek. 6G *oes not master the kno!ledge for the shelf e&am" !ith score belo! the ;<< th Ltile. EG @akes a fuss about doing their part and pickingup patients. When you are a resident" you cannot say no. JG *oes not spent ade8uate time !ith their patient to get information and keep them sufficiently informed. KG -omeone !ho does not synthesi=e information and critically think about !hat should be done ne&t. %hey may do an ade8uate ?ob at collecting the information" but cannot take it to the ne&t necessary step. 1
%he N@# FshelfG e&amination !ill comprise 2-@G. -tudents under the 1< th percentile are re8uired to retake the e&am to Pass the rotation. %hough not recogni=ed by the school" !e do use //P for those students !ho did a great ?ob on their clinical performance" but are not 8uite at the honors le$el. f you are in this category and score o$er the J5 th percentile" then your final grade !ill mo$e up to honors. %his grade designation has increased the number of honors that !e gi$e" and has not detracted from those !ho are truly clear honors. Dike!ise" !e use the /PP for those students on the borderline" and if the shelf score is o$er the E5 th percentile" then your final grade !ill mo$e up to high pass. #$ery month" there !ill be a patientsimulated e&amination or an -C# that co$ers neurology. 3ou !ill be re8uired to pass this in order to pass your rotation. n occasion" ha$e used a $ery good -C# performance to help pull up a student to the higher grade if they are truly bet!een grades. f you do not pass the -C#" you !ill get an incomplete clerkship grade until this is properly remediated. @ore information is found belo! in the section on the -C#. 4or those of you !ho are shy" softspoken" 8uiet" or obser$e from the periphery" PD#'-# make an effort to make your presence kno!n. Perhaps the most troubling thing about grading is that there are e&cellent students !ho ?ust blend into the background. %hese people do not distinguish themsel$es in the eyes of the attending or resident" and often get highpass e$en though some are talented enough to be deser$ing of honors. Yo. ,##/ to ma%# a oi,t to 'o,t$ib.t# to th# /is'.ssio, /.$i,2 th# 'o,)#$#,'#s a,/ o, $o.,/s a,/ ma%# -o.$s#") h#a$/. f no attending kno!s you at grading session" then this is a big problem that suggests your presence !as not memorable. 's a teacher" find it gratifying !hen e$eryone participates. No teacher likes a group !here pulling out discussion is like pulling teeth. f course" no one likes someone !ho monopoli=es the discussion or thinks they kno! e$erything" so you ha$e to find the correct balance. 4inally" do not determine the grade. Please do not be mad at me if you did not get honors. 'fter the rotation" may see you in the hall!ay" and !hile may not remember !hat grade you recei$ed" often can tell by !hether get a hello or not. reali=e that e$eryone is $ery smart and e$eryone is !orking hard. super$ise the process to ensure it is fair. 's you ?ust read" there are many components that need to be factored. T#ams a,/ P$#s#,tatio,s %he Neurology -er$ice is di$ided into t!o teams9 (eneral Neurology and -troke. #ach team has an attending" a chief resident" and three neurology residents. 3ou !ill be assigned to one team. Call alternates bet!een the t!o teams. When oncall" you may !orkup a patient !ho !ill be handedoff to the opposite team Fe.g. you are on the stroke ser$ice" and you admit a general neurology patientG. When you !orkup a patient to be handedoff" discuss !ith your 2 nd year neurology resident and your chief resident so you can present both patients at table rounds 'N* round on both patients at the bedside. ecause the teams round at the bedside concurrently" you !ill not be directly follo!ing the patient after your postcall day. %o facilitate bedside rounds on both your patients for the postcall day" your team should round first on your patients" and the opposite team !ill mo$e your handedoff patient to the end of the rounds list" so that you are able to ?oin. 3ou should help !ith the !orkup and tests for the handedoff patient on your postcall day" but then you should follo! the patient peripherally. nce a patient is handedoff" you can still $isit !ith the patient" read the chart" and discuss !ith others. 3ou do not !rite notes on the patient once postcall" and you !ill not be e&pected to be acti$ely engaged in patient care. When you !orkup a ne! patient oncall or on shortcall" you should staff the patient !ith the proper attending !hen the attending is physically present. 3ou should not call an attending to staff a ne! patient.
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Po"i'- o, Post1Ca"" Mo$,i,2 Co,)#$#,'# @orning rounds ha$e been starting earlier than before. n recognition of the effort spent in preparing ne! patients for morning rounds" and the $alue in ha$ing the opportunity to present your patient !hen postcall" the follo!ing policy !ill clarify priority.
1G f a conference o$erlaps !ith the time to present a ne! patient on rounds" the student may be e&cused ?ust prior to that presentation time. %his is not for follo!up presentations. 2G %he student should remain in conference for as long as they could. f they need to present a patient at E9;
Patent L)( 3ou must enter your patients into #-#D on a daily basis. f you let your patient list accumulate !ithout entering" then it !ill only become more tedious and painful. f you are seeing a patient in the hospital" you can put their sticker on an inde& card each day" and enter these at the end of the day Fbe sure to properly dispose of the cardG. 'lthough this may seem to be a bit of a nuisance" most of you !ill be doing this for the rest of your career" as attending physicians also need to turnin billing cards. %he purpose of tracking patients is to ensure you are seeing a large number of di$erse patients on your clerkship. t is also important to establish your in$ol$ement in key symptoms" diagnoses" and situations in neurology. f you performed a !orkup on a patient that included an /IP" such as on the npatient or Consult -er$ices" please note that on #-#D. f you pickedup a patient on your first day or as a handoff" and !rote daily progress notes on them" please indicate that. f students are in bet!een grades" I may use the logs to see how in"ol"ed you were in patient care in relation to the specific ser$ices you !ere on. *o ,ot enter falsified A!orkedup+ and Afollo!ed+ patients into #-#D" because if caught" !ill personally guarantee that you !ill be +#$- so$$-. f you rounded on a patient" discussed a patient in conference" or obser$ed a patient in clinic" then do enter them into #-#D" but do not check that you !orkedup and follo!ed the patient. e proacti$e in seeking out these diagnoses. 'sk other students and residents so that you !ill ha$e these all done by the end of the rotation. Please let me and your residents kno! if there are any problems seeing ade8uate patients.
Text,'( Dange+s Clinical Neurology by (reenberg" -imon" and 'minoff is a general o$er$ie! of neurology that is recommended for the clerkship. %he chapters are !ellorgani=ed" and students ha$e generally felt !ellprepared for the shelf e&am. %he grades ha$e been 8uite high for the shelf" so the correct material is in there. ecker library has an electronic copy !hich can be accessed on campus" or offcampus through a pro&y ser$er. %he only do!nside about the electronic $ersion is the inability to highlight or take notes" !hich is helpful !hen you re$ie! in the days before the e&am. ecause the book is $ery dense" !ould ad$ise that you read and highlight)take notes o$er the first 2 !eeks. %hen" spend the last 2 !eeks re$ie!ing those highlights)notes until they are memori=ed. Dange book is not Are8uired+. appreciate that students learn differently" and some do not care for this book. ha$e re$ie!ed a number of neurology books for clerkships" and there is no perfect book. ther books !hich ha$e been useful for a general o$er$ie! include Neurology Pre%est Fhighly recommended by manyG" Neurology Case 4iles" and Neurology lueprints. f you !ould like to use another book" then that !ould be fine. !ould encourage you not to read too many books or delay your reading since the rotation is so short and you !ill need to master a lot of material. @aybe do Pre%est plus one of the abo$e paperback te&ts. !ould highly recommend that you re$ie! the notes for the *iseases of the Ner$ous -ystem from 2 nd year. %his is an e&cellent resource" and you should be able to get through this 8uickly since it is already familiar. When you get your patient" you should read as much about them as possible. %his !ill include using the computers to find good re$ie!s and landmark clinical trials that are pertinent. #medicine and >p %o *ate are e&cellent sources. 3ou should also use $id. When presenting a patient in conference" you should be the group e&pert on this condition. 'n honors student !ill be able to demonstrate that they did many of these things.
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Pre2Prnte& H3P Fr"( %he residents !ill use appro$ed forms for their admission notes. 3ou should not use these for your inpatient admission notes" because there is not enough space for you to !rite on them. 3ou should use hand!ritten lined paper" or you can type your note on a computer. f you type your note" then you need to lea$e a 1 M inch margin on the left for the hole punch" and ha$e room for addressograph on both front 'N* back. e sure to clearly label your note" stamp it !ith the addressograph" add the date and time" and sign it. 3ou -/>D* use the preprinted forms !hen you are in clinic or doing consults Fi.e. #*" /ospitalG. %his is because being concise and efficient are more important in these $ery busy settings. 3ou may use them as a guide !hen talking to your patient during your inpatient !orkup.
Dre(( 3ou are a professional" so you should look the part. +m sorry that ha$e to include this" but it is important. 3ou !ant patients to trust you" tell you their deepest secrets" and to take the poisons that you prescribe on a daily basis for the rest of their life. *ressing professionally is easy" patients appreciate it" and it does make a difference. -crubs are fine !hen oncall and postcall" but other!ise use good ?udgment and prudence. 3ou should not come to !ork in the same dress that you !ear to go out !ith your friends in the e$ening. @en. 3ou should !ear a tie" dress shirt" dress pants" dress socks" and shoes. Clothes should be clean" should fit properly" and not be !rinkled. #$erything should be buttoned and tucked. 3our !hite coat should be !ashed and bleached on occasion. -ometimes a lot of bleach is re8uired. e careful not to spill the bleach on your other clothes" though. Women. 3ou should dress professionally and modestly. Clothes should fit properly" and not be o$erly tight. ne should not be able to see your backside or your belly" e$en if reaching for something o$er your head or pickingup something from the floor. 3our chest should not be e&posed Fbutton to top of sternumG. 's a general rule" there should not be e&posed flesh from the section from your neckline to your knees. Clothes should be opa8ue enough to not see under!ear. +m sorry ha$e to actually !rite this. ack in my day" seeing someone+s under!ear !as embarrassing.
Phne( an& PDA( We are fortunate to be able to communicate and use the internet from our phones. %e&ting can be an effecti$e !ay to keep the team together and pro$ide updates. /o!e$er" resist the urge to use your phone during rounds or conference. %his is e&tremely rude because it suggests you are not interested. %he attending does not kno! if you are chatting !ith your friend" or lookingup a medication" so again" $#)$ai, )$om .si,2 th#s# /#+i'#s /.$i,2 $o.,/s a,/ 'o,)#$#,'#s.
C"+%ter Ae(( 3ou !ill recei$e an email similar to the one belo!. 3our information !ill be inserted into this email. Please call Neurology Computing -er$ices !ith and problems or 8uestions. %heir phone number is EE1165. Please let @ichelle kno! if you ha$e additional problems or 8uestions. %o log on to the computers in the 11<< conference room and in the clinics please use the login information belo!. elo! is the Neuro login for9 Fstudent nameG >sername9 Pass!ord9
Flast name" first initialG 'bcd12; Fplease change at initial login to !indo!s domainG
-tudents can access C%B through the follo!ing site9 https9))neucitri&.neuro.!ucon.!ustl.edu >sername9 Pass!ord9
Flast name" first initialG 12;'bcd Fplease change at initial login to !indo!s domainG
Please let us kno! if you need any further assistance in regards to this re8uest. %hanks" Neurology Computing -er$ices EE1165
Cln( When on the 'dult npatient -er$ice" you !ill go !ith your resident to their clinic Fi.e. DD @c@illan" ConnectCare" PedsG. 3ou should stay !ith your resident during clinic" as most clinics are not staffed !ith enough attendings to facilitate students seeing their o!n patients. When on the Consult -er$ice" you !ill not go to a general neurology resident clinic. When on Peds Consults" you should attend 1 halfday clinic that !eek.
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P"#as# %## t$a'% o) -o.$ o.tati#,t '"i,i's! At th# #,/ o) th# $otatio, "#as# #mai" Mi'h#""# a 'om"#t# "ist 3ith Dat#s Tim#s S#'ia"t- a,/ Att#,/i,2s! %his !ould include general adult" peds" and adult subspecialty. We !ould like to collect this to help determine utili=ation. We may also use this as another source of student performance feedback" particularly !hen someone is $ery close bet!een 2 grades.
The OSCE n the final %hursday afternoon of the rotation" there !ill be a neuro -C#. %his is $aluable practice" as the >-@D# -tep 2 C- !ill include similar" simulated patient encounters. ased upon past e&perience" there ha$e been a number of Wash > students !ho ha$e failed the >-@D# 2 C-. 3ou do not !ant to be one !ho fails 2C- O it is $ery e&pensi$e0 'lso" Wash > student ha$e traditionally e&celled at the clinical kno!ledge section F-tep 2 CHG" but ha$e performed Aa$erage+ at the national le$el on -tep 2 C-. 3ou can prepare by9 F1G Dearning !hat is on >-@D# -tep 2 C- Fhttp9))!!!.usmle.org)#&aminations)step2)step2cscontent.html G" F2G using the clerkship -C#s and CC to practice" F;G taking the clerkship -C# and CC $ery seriously" FG asking to $ie! the $ideo of your -P encounters. %he e&am !ill consist of 1 patient encounter of 2< minutes. 3ou should come to the -C# much like you !ould come to any clinic. 3ou should be on time" appropriately dressed" establish rapport !ith the patient" and conduct yourself professionally. %his e&am is partly designed to test your interpersonal skills and professional demeanor.
3ou should bring your e8uipment. 3ou !ill be pro$ided a clipboard and piece of paper. %here !ill be a door note !ith the patient+s name" age" gender" reason for $isiting the doctor" and $ital signs. 3ou may re$ie! the door note and make notes only !hen the e&am begins. %he elements needed in the medical history !ill be determined by the nature of the patient+s problems. Not e$ery part of the history needs to be taken for e$ery patient. 3ou !ill not ha$e time to do a complete e&amination on e$ery patient" nor !ill it be necessary to do so. Pursue the rele$ant parts of the e&amination" based upon the patient+s problems and other information you obtain during the history taking. n >-@D# -tep 2 C-" you !ill ha$e 15 minutes per patient. /ere" you !ill ha$e 2< minutes per patient. 's a rough guideline" you might spent about 1< minutes on history" E minutes on the e&amination" and ; minutes on discussing diagnoses)tests)ad$ice directed at the patient. 3ou should think about !hat is necessary for a general screening neurological e&am ahead of time and practice this. %here !ill be an announcement at the start of the encounter" at 5 minutes to conclusion" and at the end. 't the end of the patient encounter" you !ill ha$e 1< minutes to complete a patient note on the computer. %his should be similar to the medical record you !ould compose after seeing a patient. 3ou should record F1G your history" including the /P" P@/" B-" -/" and 4/" F2G your physical e&am" F;G up to ; locali=ations" FG up to 5 differential diagnoses in order of likelihood" and F5G up to 5 immediate plans for further diagnostic !orkup and management. !ould recommend that you type a narrati$e" ?ust like a real /IP" because this is $ery familiar for you. f you try to make a list" you !ill probably forget something" because this is not the !ay you are used to doing it. %he Neuro -C# !ill differ from the >-@D# CC-2 by F1G 2< minutes for the encounter instead of 15 minutes" F2G inclusion of locali=ation in your note" and F;G inclusion of disease management in your note to include possible treatment" consultations or referrals. /ere are some tips9 1G e sure to knock" introduce yourself" shake hands" !ash hands" etc. %he interpersonal pleasantries count. 3ou should seek to score highly on professionalism and building rapport" since this is the same regardless of the sub?ect or situation. 2G 4ocus on the chief complaint listed on the door" but don+t neglect medications" risk factors" potential family history. *o not get boggeddo!n in B-. ;G Heep mo$ing along on the physical e&am. *on+t take 5 minutes for sensory e&am. f the patient says something is reduced or numb" take it at face $alue. %hey are not trying to trick you. %he !hole e&am should take about 6J minutes" the history 1<15 minutes" 2; minutes for opening and closing. G *o a complete screening neuro e&am. ,ust as if you are seeing a ne! patient in clinic. *o not d!ell on cognition or language unless the history suggests the need. 5G e sure to gi$e a closing statement about !hat you think may be going on" and !hat you are going to do ne&t. Closure counts.
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6G 'gain" for the postencounter" it is probably best to try to !rite a mini/IP. 3ou are familiar !ith the format" so it should flo! H. f you list out meds" -/" 4/" then you !ill not miss anything. *o not be repetiti$e. EG Writeout your e&am" ?ust as in clinic. f you don+t !rite it" you didn+t do it. e specific and detailed" meaning do ,ot !rite CN 212 intact. 3ou sho."/ abbre$iate9 'Q" con$ersant. Vision 2<)2< >" V44%C" 4undi nl" P#BBD" #@" 4ace R !ith nl sensation" hearing intact" tongue)palate straight" shoulders R. -trength 5)5" nl tone" nl 44@)toe tapping. 4N and /H- nl. -ensation intact to pin and $ibration" Bomberg absent. Befle&es symmetric" do!n toes. -tance" gait" tandem" hopping nl. JG *o not panic if the diagnosis is not ob$ious. ,ust think through the case and construct a reasonable differential.
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CONFERENCES #ore #linical #on!erence $###% $&ll students, generally Mon or 'ed ()*(+% %his curriculum re$ie!s cases and problems in neurology" and highlights many topics from the course ob?ecti$es. t is re8uired" and please come on time. 3ou !ill get more out of the conference if you look at the appropriate chapters prior to each session. %he concept is for an attending to use the dryerase board and to go through some impromptu cases to highlight important aspects about neurology !hich should be understood by anyone in any field of medicine. %hese are supposed to be clinically rele$ant" and to in$ol$e group discussion. purposely !anted to a$oid using Po!erPoint and preconstructed cases. !anted spontaneity and fle&ibility" !hile sticking to some basic predefined teaching points. %he topics for each of the sessions is listed belo!" though not necessarily in this order. %opics9 1G Neurologic /istory and #&am FClerkship @anual" Ch 11" 'ppendi& 'IG 2G *isorders of Consciousness and Coma FCh 1 I 1
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ROTATION DESCRIPTIONS AND RE4UIREMENTS INPATIENT ADULT NEUROLOGY 9b:ecti"es 1G -ee a $ariety of acute and serious neurological problems. %his !ill often include strokes" hemorrhages" infections" sei=ures" encephalopathies" intractable neurological pain conditions" inflammatory neuropathies" and demyelinating disorders. 2G Work !ithin a large healthcare team" including attendings" fello!s" chief residents" ?unior residents" and Psychiatry)Behabilitation interns. ;G Present patients concisely and thoroughly on rounds" and participate in discussion for your and other patients. G Communicate effecti$ely !ith your patient" and help to coordinate their care for the duration of their stay. 5G Work closely !ith your ?unior resident to de$elop your skills" !ork efficiently" and hone your ability to synthesi=e the history and e&am to result in a locali=ation" prioriti=ed differential" and plan for e$aluation. 6G e e&posed to outpatient neurology clinics. Description Neurology has its o!n inpatient ser$ice in this hospital. %his ser$ice is responsible for taking care of acutely ill patients !ith neurological problems" as !ell as all the other accompanying medical problems. t is a $ery concentrated e&perience" !ith a tremendous amount of teaching in a single location. Teams9 %here are t!o teams" -troke and (eneral Neurology. 'n attending and chief resident leads each team" !ith ; ?unior residents on each team F6 Fi2.$# 7!Ca"" S'h#/."#! Yo. 3i"" ha+# 88 ho.$s o)) #+#$- 0 /a-s! Yo. m.st 2o to $#9.i$#/ st./#,ts totalG. Call !ill be e$ery 6 th night" 'o,)#$#,'#s i) -o. a$# o))! Yo. /o ,ot ,##/ to 2o to $#si/#,t 'o,)#$#,'#s i) -o. a$# o))! I) -o. sta$t and the oncall team starts to take o, -o.$ 'a"" /a- 3o$% 3ith a,oth#$ $#si/#,t /.$i,2 th# /a- 5/#)a."t is /a- 0 $#si/#,t6 a,/ a"so ta%# 'a"" sta$ti,2 at 4m! I) -o. a$# sta$ti,2 o, a /a-1o)) th#, 3o$% 3ith a,oth#$ $#si/#,t patients at 5pm" staying through 5/#)a."t is /a- : $#si/#,t6! the end of the ne&t day. ' ?unior resident !ill super$ise 12 students" and sometimes an intern from Psychiatry or Behabilitation. %here are 2 'ttendings on the floor at any time" one designated to stroke and another designated to general neurology. &dmissions9 When ne! patients arri$e on the floor" they !ill be distributed by a shortcall FAshorts+G or Aoncall+ format. -horts are admissions distributed to the teams that are neither oncall nor postcall. %he oncall resident comes to the hospital at 5 pm. Ne! patients are either direct admits" hospital transfers" or come in through the emergency department. f they came through the emergency department" then they are may be !orkedup by the Neurology Consult Besident. %he attending for these patients !ill either be the !ard attending or an indi$idual faculty member. %he !ard patients !ill be those that !ill be presented postcall on rounds. Pri$ates and faculty patients are e&cellent patients to !orkup as !ell" but !ill not be presented on rounds. 3ou may also get a patient handedoff from the oncall resident if the patient belongs on the opposite -troke or (eneral Neurology team designation. 3ou !ill !rite full /IPs for ne! patients. 3ou !ill !rite progress notes on handedoff patients" unit transfers" and patients pickedup on the first days of starting npatient 'dult. 3ou may help !ith progress notes on other patients !hose resident and)or student is off.
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3ou need to see your patient before morning rounds. f you ha$e a conference that ends at the time for -re*Round -re*Round 9 3ou rounds" then you need to see your patients before the conference. PreBound includes checking !ith your resident regarding any crossco$er issues" seeing the patient !ith a pertinent history and e&am" checking the computer for test results and final radiology reports Fthese can change !hen preliminary report by radiology resident is finali=ed by atte attend ndin ingG gG"" re$i re$ie! e! $ita $itall sign signss and and note notess from from P%) P%)%) %)-% -%))-W W" see see if ther theree are are any any e$en e$entt note notess or cons consul ulta tant nt recommendations in the chart" and checking telemetry if applicable. Round Structure 9 Bounds are the primary time !hen you get to learn about patient care" obser$e the neurology history and physical" and interact !ith the rest of the team and the attendings. %hus" it is a $ery important time" and your 1st responsibility is to be on rounds. >nless there+s a patient emergency" you should be on rounds. %able rounds start in the 11<< conference room at J'@ on @)%u" J9;<'@ on W)%h" K915'@ 4riday if there is (rand Bounds. %able rounds !ill begin !ith postcall team and opposite team Fi.e. -troke team postcall" (eneral Neurology %eam %eam presentG to first hear about the handoffs. handoffs. f there !ere any patients patients admitted on short call" then these these !ill ne&t be presented to the opposite team. While this is taking place" the other team is rounding on old patients. nce all ne! patients ha$e been presented to the first attending" then the other attending !ill hear about ne! patients at table rounds. *uring this time" the first attending !ill see the ne! patients and follo!ups. Schedule @4 F$ariesG
@orning Bounds
%he follo!ing conferences are re8uired9 @onday Core Clinical Conference" Choi Conference Boom" 129<< O 19<< Fmay $aryG %uesday Neurosurgery -tudent Conference" E O J" @c@illan 5 th 4loor *r. Van -ta$ern+s Neurology #ssentials" Choi Conference Boom" O 5pm Wednesday *r. Dandau+s #thics Conference" O 59<<" last Wednesday of the block only" @c@illan th floor Conference Boom %hursday Professor:s Bounds" E9;<J915" Choi Conference Boom 4riday Neurology (rand Bounds" J O K" West Pa$ilion 'uditorium Expectations n your first day" pickup se$eral patients !ho !ill remain in the hospital for a couple days. Present updates about these patients on rounds and start to !rite progress notes. 3ou should be !orkingup about 5 ne! patients each !eek. @ost of these !ill be done independently" but there !ill be situations !hen you might !orkup a patient together !ith your resident. When oncall" you should get at least 2 ne! patients. %hese should be the 1 st 2 patients in the door. *o not !ait for an Ainteresting patient+ or a A!ard patient+. *on+t !orry if you already had a patient !ith that complaint or diagnosis. 'gain" take the first ones through the door so you can take your time and be ready to take another patient !hen you are done. n general" you should take your time !hen talking !ith your patients and e&amining them. -ometimes there might be some time constraints" and your resident !ill let you kno! !hen you ha$e to be most efficient. With no constraints" it might take 1 O 1.5 hours for a complicated patient. 4or your admission !orkup" you should stri$e to be complete and thorough. 3ou should preround on your patients each day. -ee each patient and do a pertinent neurological e&am. f f you are not sure !hat is pertinent" then lean more to!ards being complete. 4or e&le" it !ould not be a good use of your time to check $isual acuity on all of your patients if they did not ha$e a $ision problem. Dike!ise" doing a detailed sensory e&am each day is probably not !orth!hile unless specifically indicated. ut if someone came in !ith a stroke" you should do a detailed @-" language" CN" motor" and coordination e&am because !e !ould like to kno! if they !orsened or if there is e$idence for a stroke in a different location. ' ne! field cut or !eakness on the other side of the body !ould really change management in this type of patient. 's part of your prerounds" check $itals" labs" #@%#H notes" official radiology)cardiology radiology)cardiology reports" and telemetry for those !ith a bo&. 's you preround" get your note started. 4ill in the sub?ecti$e" $itals" your e&am" and labs. Dea$e a little room in case you need to add or change your e&am. f your resident gets different information from the history" or a different finding on the e&am" then fi& your note and put the correct information in your note. No! your note is ready for the assessment and plan" !hich !ill be determined !ith the rest of the team. 3ou essentially !ant to ha$e your note done as early as possible. %his is because if a Ashort+ admission comes in during the morning" then you !ant to start on the admission right a!ay. 'lso" you need to get your !ork done before you go to additional conferences and also clinic. No resident !ants to !ait around until 5 pm to re$ie! and sign your note.
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'fter the note !ith plan is completed and discussed" you should re$ie! the orders for the day !ith your resident. %his might include medications" labs" tests" and consults !ith therapists. 3ou 3ou should also be helping !ith admission orders on ne! patients. When oncall" stick !ith your resident !hen you are not !orkingup your o!n patients. !ould encourage you to be readily a$ailable if something is happening. %his is because your resident might not call you if something significant happens and they don+t see you around. 3ou 3ou don+t !ant to be obtrusi$e" but you also !ant to stay !here the action is. !ould define scut as menial !ork !ith no educational $alue that is done on a patient that you are not follo!ing. %he thing about scut" though" is sometimes menial !ork can be educational" and by freeing up time for your resident" then they could spend more time teaching you. f you ha$e a good resident that spends time teaching you" then help out !hene$er asked. 3ou should not be calling the patient+s neurology attending to discuss the case. %his is the ?ob of your resident. 4or consults" there may be some circumstances !here your resident !ould be better to call the consult rather than you. 4or e&le" if a patient needs a surgery consult" but you are unsure !hy this is necessary" then either your resident !ill need to tell you or they should make the call. n general" you should not be calling consults on patients you are not follo!ing and)or ha$e familiarity. %here are people on the floor that assist in e$aluating patients and helping !ith their discharge. %hese include Physical %herapy" ccupational %herapy" -peech)-!allo!ing)Cogniti$e %herapy" and Case Coordination. 3ou should check for their notes in the #@%#H charting system so you kno! about disposition. %he therapists !ill often make recommendations about the le$el of rehab upon discharge. -peak !ith the case coordinator as soon as disposition is approaching so they could make arrangements for home and rehab needs. f you !orkup a patient !ith a !ard attending" then you should be prepared to present on team rounds. 3ou 3ou can+t e&pect to do a presentation !ithout preparing. %he presentation should be $ery concise and pertinent" at around ;5 minutes in total. %hat means you ha$e to decide ahead of time !hat is important and !hat is not important. DO NOT READ FROM YOUR NOTE. %he B-" -/" and 4/ are usually not important for a focused presentation. %he general medical e&am should be abbre$iated in your presentation Fie. A(eneral e&am !as normalG. %he neurologic e&am should also be abbre$iated !here appropriate Fi.e. mental status and cranial ner$es !ere normalG. 3our 3our assessment should include locali=ation" a prioriti=ed differential" and a plan for in$estigation and treatment. 3ou need to go o$er these things !ith your resident" read" and practice in front of a mirror or !ith a fello! student. 3ou shouldn+t use notes e&cept for meds" $itals" and labs. 3ou should make eye contact !ith those on rounds. e in$ol$ed in discharging your patients. f they are going to a rehab or a nursing facility" then they need a transfer form !ith the medications completed. f they are going home" then they need prescriptions and follo!up appointments. (i$ing them an actual appointment for follo!up upon discharge is a good practice. 3ou !ill follo! your resident to their !eekly general neurology clinic. 3ou need to perform a neuro e&am on a patient !itnessed by your resident. 3our resident !ill gi$e you feedback after!ards" and you should hand in your feedback form so that !e kno! it got done. t is due by 2 !eeks into the rotation" but it is probably best to ha$e it done in the 1 st !eek. 3ou are not graded on this e&ercise" so this is your chance to !ork out the kinks in your e&am.
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NEUROSURGERY 9b:ecti"es 1G ecome ecome famili familiar ar !ith !ith struc structur tural al neurol neurologi ogical cal proble problems" ms" includ including ing brain brain tumors tumors"" spina spinall cord cord and ner$e ner$e root root compressions" hemorrhages" trauma" and congenital malformations !ith hydrocephalus. 2G Bound and obser$e surgeries done by a !ide $ariety of speciali=ed academic neurosurgeons. neurosurgeons. ;G 'ssist in the care of neurosurgical patients on your team" and communicate their outstanding issues effecti$ely. effecti$ely. G e e&posed to outpatient neurosurgery clinic" !hich !ill handle ne! consults as !ell as postsurgical postsurgical follo!up. Description Befer to the Neurological -urgery -yllabus for details. 3ou should attend any appropriate Neurosurgery conferences during your block that do not conflict !ith the re8uired Clerkship conferences. Schedule n addition to the Neurosurgery Conferences" you are re8uired to attend the follo!ing Clerkship Conferences9
@onday
@eet !ith *r. Dimbrick Dimbrick at Jam on first day of clerkship in Children:s /ospital" th 4loor" -uite -2< FNeurosurgeryG Core Clinical Conference" Choi Conference Boom" 129<< O 19<<
%uesday
Neurosurgery -tudent Conference" E O J" @c@illan 5 th 4loor *r. Van -ta$ern+s Neurology #ssentials" Choi Conference Boom" O 5pm *r. Dandau+s #thics Conference follo!ed by Course #$aluation" O 59;<" last Wednesday of the block only" @c@illan th floor Conference Boom Professor:s Bounds" E9;<J915" 1<5<< Conference Boom J9;
Wednesday %hursday 4riday
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NEUROLOGY HOSPITAL CONSULTS 9b:ecti"es 1G -ee a $ariety of acute and serious neurological problems" including metabolic encephalopathies" iatrogenic CNcomplications" CN- infections" stroke" CN- complications of cancer" headaches and pain" loss of consciousness" post code prognostication" myopathies. 2G Work !ithin a large team" consisting of an attending" a senior neuro resident" a ?unior neuro resident" and sometimes a medicine resident. ;G Present patients concisely and thoroughly to attendings on rounds" and participate in discussion for your and other patients. G #nsure effecti$e communication of the neurological plan to the re8uesting physicians" and follo!up on the results. 5G Work closely !ith your senior FP(3;G and ?unior resident FP(32G to de$elop your skills" !ork efficiently" and hone your ability to synthesi=e the history and e&am to result in a prioriti=ed differential and plan for e$aluation. 6G e e&posed to outpatient neurology" through a !eekly general clinic. #linics
3ou should go to 2 utpatient -ubspecialty Clinics each !eek !hile on consults for the 1 st three !eeks of the clerkship. -ince the last !eek of the clerkship is short" you should only go to 1 clinic. Be$ie! the clinic schedule !ith your senior P(3; resident and ask for some assistance in picking the clinics based upon your interest and time a$ailability. 3our resident !ill help direct you to some of the better clinics" and !ill also kno! !hen you are not a$ailable to take patients or round. 3our resident may recommend doing an '@ and P@ clinic on the same day" or splitting the days. nce the clinics are picked" email the attending ahead of time to introduce yourself" ensure that a full clinic is planned" and to get a firm start time. -ome may !ant you there a fe! minutes before the 1 st patient to make things run more smoothly. Clinics can also $ary !ith people on $acations" on ser$ice" at meetings" etc. At th# #,/ o) th# b"o'% "#as# #mai" Mi'h#""# a "ist o) th# '"i,i's -o. att#,/#/! This sho."/ i,'"./# th# s.bs#'ia"t- '"i,i's /.$i,2 'o,s."ts AND 2#,#$a" '"i,i's /.$i,2 I,ati#,t A/."t! We !ould like to keep track of !hich clinics are being utili=ed. We may ask some clinic attendings for comments during the e$aluation process. Resident 7ounge %he students on consults may be included in the resident lounge on 1<<< if there is patient care taking place in that location. -tudents not on consults should not use the lounge due to space restrictions. Hnock on the door" and your resident !ill let you in. Description Neurology Consults are split bet!een t!o teams. ne team !ill !orkup ne! consults in the hospital and #mergency *epartment during the morning FEam O 1pmG" and !ill round !ith the attending in the afternoon Fafter 1pmG. %he second team !ill round !ith the attending in the morning Ftime decided based upon censusG" and !ill !orkup ne! consults from the floor and #* in the afternoon F1pm O EpmG. #ach consult team !ill be run by ;rd year neurology resident and an attending. %here is usually a 2 nd year neurology resident" along !ith some medicine residents. 3ou should !orkup at least 12 ne! patients each day. -ome days !ill be $ery busy for the resident" and there might not be much time to discuss the patients before it+s time to round !ith the attending. -ome days !ill be lighter" and the resident can re$ie! things !ith you. 3ou !ill likely ha$e ample time to independently assess your patients and do some 8uick reading about their problem. 3ou may use the preprint /IP notes for your !riteup" clearly labeling it as a student note at the top and !ith your signature. b$iously" ne$er mark a checkbo& on the form if you did not perform that part of the e&am. f rounds go past 6pm" you are e&pected to stay until rounds are complete. 3ou do not need to come in during the !eekend. 'lthough there is not a designated formal teaching time" you !ill actually learn a lot in rounding on all the patients. 3ou also ha$e the potential for a lot of direct interaction !ith the attending. Schedule @ O 4 E '@ 7
@eet your resident in 11<< Conference Boom. %he Neurology Consult pager is 2K1;26
%he follo!ing conferences are re8uired9 @onday Core Clinical Conference" Choi Conference Boom" 129<< O 19<< Fmay $aryG %uesday Neurosurgery -tudent Conference" E O J" @c@illan 5 th 4loor
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Wednesday %hursday 4riday
*r. Van -ta$ern+s Neurology #ssentials" Choi Conference Boom" O 5pm *r. Dandau+s #thics Conference" O 59<<" last Wednesday of the block only" @c@illan th floor Conference Boom Professor:s Bounds" E9;<J915" 1<5<< Conference Boom Neurology (rand Bounds" J O K" West Pa$ilion 'uditorium
Expectations 3ou should ha$e plenty of time to re$ie! the medical record" talk !ith the patient and e&amine them" and do a brief !riteup. f the story is not clear !hen talking !ith the patient" then you should call additional sources. %hese might include their ne&t of kin" the nursing facility that takes care of them" etc. ,ust be a!are that you cannot gi$e out medical information to family members !ithout the patient+s consent" so ask the patient if it !ould be H if you called to get more information. Work efficiently" and contact your resident as soon as you are done. 'lso be a!are that !e are not the primary team caring for the patient" and are usually called to ans!er a specific neurologic 8uestion. @ost good consults are formulated in a 8uestion or a re8uest to e$aluate for a specific problem. 3our resident !ill often gi$e you this 8uestion !hen s)he assigns you a patient. -ince you are a consultant" in many cases the communication about your findings and opinion !ill be directed to the physician re8uesting the consult and not the patient or their family. 3ou also don+t !ant to get in$ol$ed in the fine details of medical care outside that !ithin the realm of a neurologist. 's t!o more re8uirements" you need to perform a neuro e&am on a patient !itnessed by your resident. 3our resident !ill gi$e you feedback after!ards" and you should hand in your feedback form so that !e kno! it got done. t is due by 2 !eeks into the rotation" but it is probably best to ha$e it done in the 1 st !eek. 3ou are not graded on this e&ercise" so this is your chance to !ork out the kinks in your e&am.
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PEDIATRIC NEUROLOGY CONSULTS 9b:ecti"es 1G -ee a $ariety of acute and serious pediatric neurological problems. %his !ill often include metabolic encephalopathies" de$elopmental problems" iatrogenic CN- complications" CN- infections" stroke" CN- complications of cancer" headaches and pain" e$aluating loss of consciousness and sei=ures" myopathies. 2G Work !ith a team of an attending" a pediatric neuro fello!" an adult neurology resident. ;G Present patients concisely and thoroughly to attendings on rounds" and participate in discussion for your and other patients. G #nsure effecti$e communication of the neurological plan to the re8uesting physicians" and follo!up on the results. 5G Work closely !ith your attending and pediatric neurology fello! to de$elop your skills" !ork efficiently" and hone your ability to synthesi=e the history and e&am to result in a prioriti=ed differential and plan for e$aluation. 6G e e&posed to outpatient neurology" through 2 !eekly M day peds clinics. EG e comfortable performing a neurological e&am on neonates" through teenagers. Description %!o !eek consult rotation at -t. Douis Children+s /ospital" co$ering the hospital and emergency room. 3ou !ill be asked to e$aluate acute neurological problems of a di$erse nature. Schedule @4 F$ariesG
Page the consult Peds resident. %he pager is J2;<;2;. n 4riday attend Neurology (rand Bounds
%he follo!ing conferences are re8uired9 @onday Peds rientation !ith *r. Darsen" 12 th floor NW %o!er" E9;< O Jam Core Clinical Conference" Choi Conference Boom" 129<< O 19<< F119;< on 1 st *ayG %uesday Neurosurgery -tudent Conference" E O J" @c@illan 5 th 4loor Pediatric Neurology *i$isional Conference" E9;< O J9;
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#EEKLY GENERAL NEUROLOGY CLINICS 'BN#- CDNC %his is a !eekly continuity clinic for the residents located in the basement of @c@illan /ospital. t starts at 19<< and is on @onday" %uesday" %hursday" and 4riday. oth ne! and follo!up patients are scheduled !ith the residents. 3ou should stay !ith your resident during the clinic. CNN#C%C'B# CDNC %his is a !eekly continuity clinic for residents located on *elmar" ?ust east of *e ali$iere '$e. t starts at 19<<" and is on @onday and 4riday. 3ou should either shado! the attending if he)she is seeing patients" or shado! your resident.
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SUR5I5AL GUIDE *r the NEUROLOGY CLERKSHIP Bob Naismith" @.*. The Ne%rl)al H(tr$ %he history is the most important part of your !orkup. @ore so in any other field of medicine" the history is instrumental in making the diagnosis in neurology. %his is because most diseases in neurology do not ha$e a diagnostic test. %he e&am is $ery helpful" but rarely specific. Without a good history" it is usually impossible to come to the correct ans!er. -ome say if you do not ha$e a differential diagnosis by the end of the history" then you should take the history again. %he history is also ho! !e learn about disease and ho! it affects people. Beading a te&tbook can ne$er replace personally hearing the story and e&amining 2 or 2< or e$en 1<
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't the end of the history" you should ha$e a clear picture of their symptoms and ho! they ha$e unfolded o$er time. 3ou should also ha$e some hypotheses about !hat you !ill find on e&am and a start to your differential. 3ou should also ha$e some inside kno!ledge about !ho is this person" ho! has their disease affected them" and !hat is their social support and li$ing situation.
The Ne%rl)al Exa" ne of the great things about neurology is the physical findings and their tremendous usefulness for locali=ing and deciding about the diagnosis. 'lmost e$eryone !ith a neurological disease Fe&cept sei=ures and headachesG !ill ha$e some abnormalities on their e&am. -ome of these are 8uite striking" and some can be $ery subtle. 3ou cannot learn these in a book or a single lecture" so !e learn this by seeing patients together !ith those !ho are more e&perienced. When you round !ith attendings" they !ill point out the subtle findings. Watch carefully ho! your attending does the e&am" because e$erything has a purpose. 3ou should do a complete neuro e&am on all your patients" at least for the initial !orkup. %he chief or the attending might do a more focused e&am" but that+s not the goal for you at this time. 3ou need to ha$e a firm grasp of !hat is normal and !hat is abnormal" and that takes much practice. @ental status can be a large or a short part of the e&am. n e$ery patient" you should specifically check orientation Fperson" place" time" situationG" recall" shortterm memory" attention" calculations" and longterm memory. 3ou should take the persons educational le$el into conte&t here. %hese can be e&panded upon depending on the story and other findings. Danguage consists of 6 components. %hese include comprehension" fluency" naming" repetition" reading" and !riting. Cranial ner$es should include $isual acuity and funduscopic e&am. 3ou need to be able to readily see the optic ner$e before the end of the rotation. 4or the motor e&am" you need to be able to pickup subtle !eakness. %his !ould include ha$ing people do fine finger mo$ements" toe tapping" !alking on heels and toes" and hopping on each foot if safe to do so. When you check po!er" be sure that you ha$e the mechanical ad$antage so that you !ill kno! if they ha$e mild !eakness. Bemember that for refle&es" you are trying to detect subtle differences" not ?ust !hether they are present or absent. When you perform the e&am" it is much like an e&periment !here you are hypothesis testing. 'fter you obtain the history" go !ash your hands and use that time to create your hypotheses. %hink about the locali=ationFsG" and the possible diagnoses on your differential. *o not bias the e&am too much by leading the patient. 3ou can conduct it as an ob?ecti$e e&periment" and be con$inced that the abnormality is really there. f you are not sure" repeat the test until you are con$inced. *o more detailed testing !hen indicated by the history. 4or e&le" it may take 15 seconds to elicit the refle&es if they ha$e no symptoms referable to that system" or it may take 2; minutes if you are really trying to discern a difference. #rte2U+( 3our !riteups on neurology should be clear and concise. %here is no reason to !rite a te&tbook summary as your assessment. %he history should be $ery detailed and lengthy. %his is because it is the most important part of your !orkup. f the history is 12 short paragraphs" then this is not enough. %he social history should gi$e an indication of the person+s li$ing situation and social support. #$en though alcohol" drug abuse" and tobacco use are really medical problems" they ha$e been traditionally included under social history. %he real social history !ill include educational le$el" ?ob position !ith specific details" li$ing situation" financial situation" important hobbies" etc. 3our assessment should contain a brief" 12 sentence statement !hich summari=es the entire !orkup. Write this statement as if no one !ill read your !riteup e&cept the assessment. 4or e&le" %his is a 6E y)o man !ith cardiac disease !ho presents !ith sudden onset of slurred speech and leftsided !eakness" and is found to ha$e a left hemiparesis and neglect on e&am. C% sho!ed e$idence of pre$ious strokes" but nothing identified as acute. %he ne&t part of your assessment should include locali=ation. e only as specific as you can. 4or e&le" if there is left hemiparesis alone" then you could only say that it could be in the right hemisphere or brainstem. f someone has left hemiparesis densely in$ol$ing arm and leg !ith a dense field cut and ga=e de$iation and a global aphasia" then you kno! that there is a stroke in the entire @C' territory on the right. %he ne&t part of your assessment discusses the differential diagnosis. 3ou should prioriti=e your differential" and not ?ust make it into a long laundry list. What are the most possible diagnoses that are pertinent to this person+s story7 %hat is" you need to integrate the !hole story" and demonstrate that you understand !hat is going on here. 'l!ays include things that are common" treatable" and)or dangerous. /a$e a brief discussion as to !hy something is higher in the differential than another" or !hy it is less likely. %his !ill include re$ie!ing the diagnoses in a te&tbook and the medical literature. Be$ie! papers are a good place to start.
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n constructing differentials" it is good to ha$e a frame!ork in !orkingthrough the different categories of disease. %he follo!ing mnemonic is good to use9 * O *egenerati$e and hereditary V O Vascular Finfarct" ischemia" hemorrhageG O nfectious Fimmunocompetent" immunocompromised" bacterial" $iral" fungal" parasiticG C O Cancer Fmass effect" paraneoplasticG % O %rauma and surgical O mmunologic Fautoimmune" allergicG @ @etabolic Fnutritional deficiency or e&cess" organ dysfunction" electrolyte disturbanceG 4inally" put your plan and the reason for doing these things. 4or e&le" obtain @B to see if there is e$idence of acute infarcts in both hemispheres" consult P% to assist in gait training" obtain cardiac echo to e$aluate for thrombus or $al$ular abnormality. *on+t put in plans for neurological emergencies if you aren+t going to do them. 4or e&le" don+t !rite to consider an DP if bacterial meningitis is a possibility" or consider ##( if noncon$ulsi$e status is a possibility. f you thought these !ere possibilities" you probably !ould ha$e done the test before doing the !riteup.
Pre(entatn( 3our ?ob for a presentation is to clearly and concisely reconstruct the timeline from the beginning" gi$ing details about their symptoms as you go along. %here are 2 types of presentations. %he first is the ;5 minutes $ariety" and the second is the fullblo!n conference $ariety. 3ou should be able to do either presentation !ithout reading from your notes. 3ou could ha$e a list of the medicines !ith doses" the $itals" and the labs" but reading the history is bad. 3ou need to be able to look people in the eye and grab their attention. Bemember" e$eryone is going to be tired and thinking about the other 1< things they need to do at the moment. f you gi$e a boring presentation" then no one !ill pay attention. !ould al!ays try to put the story in the proper conte&t !hen rele$ant" e$en for the ;5 minute presentation. 4or e&le" if someone !ent to the county fair and rode the roller coaster" and an hour later de$eloped $ertigo" slurred speech" and inability to !alk" then this gi$es us the conte&t in !hich a $ertebral dissection might ha$e occurred. t also makes the story uni8ue and memorable. f someone de$eloped a headache !hile ha$ing se&" then this might be rele$ant for subarachnoid hemorrhage. f someone !as in church singing in the choir and they passed out" then this is rele$ant. f you !ere to ?ust list the symptoms !ithout the conte&t" then it is more boring and the patients start to sound the same. %he :14 mi,.t# $#s#,tatio, !ill be !hat is used during %eam Bounds. %his is a barebones presentation" but it is $ery dense !ith rele$ant material. t is really the Atip of the iceberg+ in terms of !hat you kno! about the patient. 3ou cannot tell us e$erything" so you ha$e to decide on !hat you do tell us. t consists of a chief complaint and the history. 3ou should state pertinent positi$es and negati$es along the !ay depending upon the differential diagnosis. %here is no re$ie! of systems in the ; minute presentation. f the family history is not rele$ant" then don+t e$en both to mention it. f the social history is rele$ant" then include it in the history. f a past medical problem is rele$ant" then include it in the identifying information 4or e&le" %his is a 6E y)o B/ !hite man !ho presents !ith acute onset of slurred speech. /is history is significant for atrial fibrillation" congesti$e heart failure" coronary artery disease" and a pre$ious stroke in 2<<5 !ith residual mild left hemiparesis. We do not care !hether they had their gallbladder or tonsils out" or if they ha$e seasonal allergies unless it is rele$ant. We do not care if they take Prilosec unless it is rele$ant. ottom line is that the attending should ha$e a $ery clear picture of !hat is going on !ith this person !ithin a fe! moments. %here are no guessing games or cards to be kept up ones slee$es. ,ust go ahead and say it like it is. When presenting to the attending on rounds" put the chief complaint up front and in medical terms. *o not use the patients !ords unless they are particularly rele$ant or insightful. Consider the follo!ing e&le" @r. ,ones is a E2 y)o B/ black man !ith C'*" /%N" hypercholesterolemia" (#B*" and arthritis !ho presents because his daughter insisted he come to the hospital. 3ou are no! 15 seconds in the presentation and the attending has no clue. y gi$ing the medical complaint up front" the attending can start to organi=e your presentation. No! consider the opening statement in the paragraph abo$e. Bight from the start" the attending kno!s the complaint Fslurred speechG" along !ith age and gender. s it 'D-7 s it a ell+s palsy7 s it a stroke7 %hese are going through the attending+s mind. Ne&t s)he hears a list of cardio$ascular risk factors" and immediately stroke goes to the top of all considerations. %hat is ho! the brief presentation should !ork. 3ou should present the details" almost anticipating !hat needs to be heard at that gi$en time. %he e&am should be abbre$iated to con$ey !hat is important. 'lso" remember to stay organi=ed9 1G mental status" 2G language" ;G cranial ner$es" G motor" 5G refle&es" 6G sensory" EG coordination and gait. We are all going on the assumption that you did a complete general and neurological e&am. t !ould be fine to list out the $itals and then say that the general medical e&am is unremarkable if that is !hat you found. 4or a stroke" you might say mental status and language are intact. Cranial ner$es are rele$ant for left lo!er facial droop and dysarthria" but no field cut. @otor is rele$ant for a left hemiparesis ;)5 in se$erity affecting the arm greater than the leg. Befle&es are brisk on the left !ith an upgoing toe. Coordination on the left !as appropriate for that degree of !eakness. /e had diminished sensation on the
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left" but !as able to reliably percei$e touch. /e had both $isual and sensory neglect. /e needed assistance to !alk due to the hemiparesis. 3ou generally don+t !ant to get bogged do!n in listing out all the cranial ner$es" all the numbers for the muscle testing" and all the numbers for refle&es. 3ou !ant to include pertinent negati$es here based on your differential. %his is ho! your attending !ill kno! you are smart. f bacterial endocarditis is on the differential" then you should specifically state in the general e&am that there !ere no con?uncti$al or e&tremity lesions and no murmur. ecause the presentation is brief" you shouldn+t ha$e to gi$e a summary statement of !hat you ?ust said. 3ou should gi$e a statement about the locali=ation" and then the differential diagnosis. %he differential should be ranked to include things that are common" things that are treatable" and things that are dangerous. Ne&t you can state your plan for e$aluating the differential and for helping the patient get better. 3ou !ill need to prepare for the ;5 minute presentation. *on+t think you could do it other!ise. t takes practice to condense 12 hours of your !orkup into 5 minutes. %he attending reali=es you spent a lot of time !ith your patient" but doesn+t !ant to hear e$ery last detail. 3ou !ill sho! the attending ho! smart you are by ho! !ell you are able to do this. Dosing focus and going on a tangent !ith your presentation !ill not impress. -ome of your grade !ill come from this interaction. Behearse out loud in your call room" or find another student to help practice. %he 'o,)#$#,'# $#s#,tatio, is 8uite different" and is not often used on neurology. %his is typically done sitting at the table !ith the attending and all the students. t is primarily a forum for discussion and teaching. /ere" there is sometimes a sense of drama" because !e !ant to ha$e a good discussion based on the symptoms. 'gain" you shouldn+t read off your note" but the presentation !ill be constructed much like your note. 3ou !ant to gi$e a chief complaint and the history. /ere" the chief complaint !ould probably be best in the patient+s !ords for the sake of discussion. %he attending might ask you to stop along the !ay so that there can be some discussion. 3ou should gi$e the complete P@/ and @eds. 3ou should include the social history and family history. (i$e the neuro e&am in detail" by listing out the specifics. 3ou also need to prepare for this" but not in the same !ay as the ;5 minute presentation. %his is because your classmates !ill be asked to contribute to the discussion and to help ask the rele$ant 8uestions. 3ou need to be sure that you ha$e all the ans!ers. 3ou also need to be an e&pert in this person+s diagnosis. %his !ould include re$ie!ing the rele$ant literature and e$idence. Dastly" don+t forget that your attending !ill like to hear the neuro e&am in order. %his is 1G @ental status" 2G Danguage" ;G Cranial ner$es" G @otor" 5G Befle&es" 6G -ensory" EG Coordination I gait.
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->PPD#@#N%'B3 @'%#B'D Ne%rl)al Da)n(( 'llyson B. Ua=ulia" @.*. +m sure you+$e heard the stereotype that sure" the brain is fascinating" but all neurologists do is mental masturbation" spending their time in the useless intellectual e&ercise of pinpointing !hich nucleus or tract or other structure is in$ol$ed in a patient+s illness !hen !e all kno! that it doesn+t matter any!ay because there are $irtually no treatments for neurological disease. @y ?ob today is not to try to con$ince you that there is no greater specialty than neurology or to dispel the belief that !e ha$e nothing to offer patients !ith neurological disease. Bather" am going to focus on the process of neuroanatomical locali=ation" !hy it is uni8ue" and ho! it is central to neurological diagnosis. >nderstanding neurological pathophysiology is important not only for neurologists and neurosurgeons9 @any neurological disorders are commonplace in general medical practice or other specialty. Patients !ith headache" stroke" or carpal tunnel syndrome are often managed !ithout a neurological specialist e$er being consulted. ' number of neurological diseases are caused by or !orsened by general medical disorders or occur as complications in patients hospitali=ed for other reasons. -imilarly" neurological disturbances may occur as part of or may e$en be the first sign of a systemic medical condition. /o! do you make a neurological diagnosis7 n many !ays the strategy is the same as making any diagnosis in medicine. 4irst" you locate the patient+s symptoms and signs anatomically. -econd" you interpret temporal features in terms of pathophysiological principles. %hird" you use the results of these t!o e&ercises to formulate an etiological hypothesis.
Lal6atn -imply defined" locali=ation means !here" i.e." !here !ithin the ner$ous system is the lesion responsible for a patient+s symptoms and signs. F>nderstand that lesion does not necessarily imply a $isible structural defect rather" it is used synonymously !ith dysfunction.G %hus" locali=ation re8uires a thorough understanding of the anatomy and physiology of the ner$ous system" its blood supply" and the disease processes that affect it. %he process of locali=ation begins during history taking" is refined during the general and neurological e&aminations" and is reassessed after any rele$ant diagnostic studies are completed. 'lthough sophisticated neuroimaging and laboratory studies are in continuous de$elopment" technology cannot replace the clinician+s anatomical locali=ation based on history and e&amination. Desions may go undetected on standard imaging studies unless the studies are specifically focused on the anatomical region hypothesi=ed to be in$ol$ed. -imilarly" neuroimaging or laboratory studies may disclose incidental abnormalities that ha$e no bearing on the patient+s symptoms and the further pursuit of !hich can lead to unnecessary time" e&pense" and potentially e$en patient harm. %ake the case of a patient !ith back pain and difficulty !alking. n the absence of a thorough / I P and lesion locali=ation" an @B of the lumbar spine is obtained" sho!ing a left D5 disc herniation. %he patient is sent to an orthopedist and undergoes discectomy. 't best" his symptoms do not impro$e !ith surgery or continue to progress. 't !orst" he de$elops a serious postoperati$e complication. /ere+s the !ay it should ha$e !orked9 4urther history re$eals that the pain !as not radicular Fas !ould occur !ith a discGS !alking !as difficult because his legs felt stiff and he couldn+t feel the ground !ith his feet" and he had been ha$ing urinary urgency and incontinence as !ell as impotence for the past 6 months. ased on these symptoms" your hypothesis at this point is that he has a spinal cord lesion. -ince you kno! that the spinal cord ends at D2" you kno! that there is no role for imaging of the lumbar spine. #&amination re$eals tenderness o$er the lo!er thoracic spine" full strength" bilateral lo!er e&tremity spasticity and hyperrefle&ia !ith e&tensor plantar responses Fupgoing toesG" and sensory loss belo! %K. 3ou can no! further refine your locali=ation to the thoracic spinal cord and order the appropriate imaging study" !hich sho!s an e&tradural mass at %E compressing the spinal cord. %he moral of the story is not that you don+t need an imaging studyit+s that your clinical skills and your kno!ledge of neuroanatomy are essential to guiding appropriate diagnostic e$aluation and to determining the significance of any abnormalities detected in that e$aluation. Docali=ation in$ol$es t!o separate steps9 576 type locali=ation and 5*6 topographical locali=ation. T-# "o'a"i;atio, identifies the type of dysfunction present !ithin the ner$ous system. %here are fi$e possibilities9 focal" multifocal" diffuse" specific system" and combination. 7! ' )o'a" lesion is one in !hich a single" discrete neuroanatomical locus can account for all the patient+s symptoms and signs. #&les include 5a6 a left cerebral hemispheric infarction in a patient !ith sudden onset right hemiplegia and aphasiaS 5b6 a pituitary tumor in a patient !ith papilledema and subacute onset amenhorrhea and bitemporal hemianopiaS and 5'6 a right median neuropathy in a patient !ith !eakness of the right abductor pollicis bre$is and numbness of the first ;M digits on the right hand. V6.15.11
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*! ' m."ti)o'a" process in$ol$es more than one locus" but the loci remain discrete. @odification of the pre$ious e&les that !ould indicate multifocal locali=ation include 5a6 multiple cardiacorigin emboli in a patient !ith a ne! systolic heart murmur and sudden onset right hemiplegia and aphasia Fleft cerebral hemisphereG and left superior 8uadrant $isual field cut Fright posterior temporal hemisphereGS 5b6 metastases in a smoker !ith chronic cough" papilledema" and subacute onset left arm and leg dysmetria Fleft cerebellar hemisphereG and left homonymous hemianopia Fright optic tractGS and 5'6 mononeuritis multiple& Fneuropathy in$ol$ing multiple discrete ner$esG in a patient !ith !eakness of the right abductor pollicis bre$is and numbness of the first ; M digits on the right hand Fright median ner$eG" tingling in the fifth digit and the ulnar half of the fourth digit on the left hand and !eakness of the left first dorsal interosseus Fleft ulnar ner$eG" and numbness of the left lateral leg and dorsal foot and !eakness of left ankle dorsifle&ion and e$ersion Fleft superficial peroneal ner$eG. :! Di)).s# locali=ation indicates !idespread dysfunction of a part of the ner$ous system. #&les include 5a6 encephalopathy due to a $ariety of metabolic or to&ic causesS 5b6 dementiaS and 5'6 numbness and pain in a stocking and glo$e distribution due to diabetic small fiber peripheral neuropathy.
Note that in both a multifocal and a diffuse process" there is in$ol$ement of more than one discrete physical location. ut in multifocal" the lesions remain discrete" !hereas in diffuse" the dysfunction is generali=ed. n the case of neuropathy" for e&le" a multifocal process !ill be e$ident by signs and symptoms in the distribution of multiple specific ner$es Fe.g." median" ulnar" and femoralG" as discussed in the e&le of mononeuritis multiple& abo$e. -ome ner$es are in$ol$ed and some aren:t. n a&onal neuropathy Fa form of diffuse ner$e diseaseG" on the other hand" the distalmost portions of all a&ons are in$ol$ed" resulting in stocking and glo$e distribution sensory and motor loss. a! S#'i)i' s-st#m locali=ation is a subset of diffuse locali=ation. n specific system processes" there is diffuse dysfunction of a particular path!ay or neurotransmitter system. %he progressi$e diffuse !eakness" atrophy" fasciculation" and spasticity in amyotrophic lateral sclerosis FDou (ehrig:s diseaseG occur because of loss of the anterior horn cells and degeneration of the corticospinal tracts. %he progressi$e loss of $ibration and proprioception in $itamin 12 deficiency is a manifestation of posterior column dysfunction. %he delirium" mydriasis" hypertension" dry mouth" urinary retention" and constipation of atropine o$erdose reflect blockade of muscarinic cholinergic receptors.
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in$ol$es determining the anatomical le$el !ithin the ner$ous system that accounts for all the patient+s findings. ften" it is best to start from the periphery and !ork centrally" considering each of the possible sites listed in the table belo!. %he middle column lists the terms commonly used to describe the disease processes affecting these areas and the right column lists the symptoms and signs typical of lesions at these sites.
T+)ra+hal
"o'a"i;atio,
Sit# P#$ih#$a" @uscle Neuromuscular ?unction Peripheral ner$e
Ple&us Fbrachial lumbosacralG -pinal ner$e root Ner$e cell body 'nterior horn cell *orsal root ganglion Si,a" 'o$/
D-s).,'tio,
T-i'a" s-mtoms
@yopathy
Pro&imal !eakness Fmotor onlyG 4atigable !eakness Fmotor onlyG PainS motor" sensory" and refle& loss in specific ner$e distribution" B distal symmetric sensory loss and)or !eakness @i&ed ner$e and root distribution
Neuropathy
or Ple&opathy Badiculopathy
Badicular painS motor" sensory and refle& loss in specific root distribution
D@N disease -ensory neuronopathy
D@N !eakness and refle& loss -ensory loss and refle& loss
@yelopathy
D@N !eakness at le$el of lesionS >@N belo! le$el of lesionS sensory le$elS dissociated sensory lossS neurogenic bladder
Post#$io$ )ossa rainstem
Cranial ner$e deficitsS impaired DCS crossed or bilateral motor or sensory deficits 'ta&iaS tremorS nystagmus
Cerebellum S.$at#,to$ia" %halamus
asal ganglia Cerebral corte&
#ncephalopathy
DC or memory disturbanceS hemisensory loss and)or painS hemiata&iaS neglect or aphasia ChoreaS athetosisS dystoniaS tremorS rigidity /emiplegia F>@NG and)or hemisensory lossS aphasiaS neglectS hemianopiaS dementiaS sei=ure
Oth#$ -ubarachnoid space)meninges
/eadache" altered DC" cranial ner$e deficits D@NRlo!er motor neuron9 !eakness" atrophy" refle& loss" fasciculations. >@NRupper motor neuron9 !eakness" spasticity" hyperrefle&ia" e&tensor plantar response. V6.15.11
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DCRle$el of consciousness. %his is !here your kno!ledge of neuroanatomical path!ays and the signs and symptoms that go along !ith damage to these path!ays comes in. -ince the ner$ous system is a continuum" a particular symptom may represent a lesion at multiple le$els. %hus" a complaint of !eakness may represent dysfunction at the le$el of the muscle" neuromuscular ?unction" peripheral ner$e" ple&us" spinal ner$e root" lateral column of the spinal cord" pyramidal tract in the brainstem" internal capsule" or cerebral motor corte&. t is the att#$, of !eakness Fe.g." pro&imal $s. distal" unilateral $s. bilateral" face $s. limbsG" asso'iat#/ s-mtoms Fe.g." numbness" $isual disturbance" language dysfunctionG" and #=ami,atio, )i,/i,2s Fe.g." atrophy" fasciculations" and hyporefle&ia or spasticity and hyperrefle&iaG that allo! you to narro! do!n the possibilities. -o" for e&le" !eakness" numbness" and refle& loss !ithin the distribution of a particular spinal ner$e root implies a radiculopathy" !hereas !eakness of the face" arm" and leg all on the same side of the body implies a lesion !ithin the motor path!ays abo$e the le$el of the facial nucleus in the midpons. *uring the process of locali=ation" ask yourself three 8uestions9 7! What is the necessary minimal amount of neuroanatomy that m.st b# damaged in order to produce the patient+s symptoms)signs7 ' patient !ith monocular blindness m.st ha+# a lesion on the same side some!here bet!een the cornea and optic chiasm. ' patient !ith an absent tendon refle& m.st ha+# a lesion !ithin the afferent efferent arc ser$ing that refle&. ' patient !ith aphasia m.st ha+# a lesion of the dominant FK5L leftG cerebral hemisphere. *! f the lesion is here" does it e&plain a"" the findings7 f the ans!er is no" you should carefully ree&amine the data and your conclusions. #ither the locali=ation is !rong or the disease process is multifocal or diffuse. :! f the lesion is here" !hat #"s# should be present7 %hat+s another !ay of saying" does the patient ha$e the e&pected ,#i2hbo$hoo/ si2,s to go along !ith your proposed locali=ation7
Det+s take the complaint of unilateral facial !eakness. With this small amount of information Fface and unilateralG" !e can already narro! do!n the possible sites of in$ol$ement to peripheral ner$e Fcranial ner$e VG !ithin subarachnoid space or temporal bone" brainstem Fpontine lesion affecting the V ner$e nucleus or fasciclesG" or supranuclear motor path!ays supplying the face Fe.g." genu of internal capsule or lateral motor corte&G. ut !e ob$iously need to do better than this before beginning to address !hat the patient has. %he first 8uestion should be !hat is the pattern of !eakness7 f the patient has lo!er facial !eakness Fdrooping at the corner of the mouth or inability to raise the corner of the mouth !hen smilingG !ith relati$e sparing of the upper face" this is consistent !ith an upper motor neuron lesion Fa.k.a. supranuclear or abo$e the le$el of the facial nucleus in the ponsG. f instead the patient has !eakness that in$ol$es the entire half of the face e8ually Ffacial droop as !ell as inability to close the eyeG" this is consistent !ith a lo!er motor neuron lesion Fat the le$el of the V ner$e or the V ner$e nucleus in the ponsG. ur patient complains of both facial droop and inability to close the eye. -o no! !e need to differentiate bet!een a pontine lesion and a peripheral ner$e lesion. What neighborhood signs !ould you e&pect !ith a lesion of the facial nucleus or intrapontine ner$e fibers7 f you remember your brainstem anatomy For pull out a diagram of the pons" see Fi2.$# 7G" you+ll recall that the facial ner$e fibers course around the abducens nucleus and that the abducens ner$e fibers course ?ust medial to the facial nucleus as they e&it the pons. %he parapontine reticular formation lies ?ust $entromedial to the abducens nucleus. -o an associated ipsilateral lateral rectus palsy or con?ugate ga=e palsy !ould locali=e the lesion to the pons. -ince the facial ner$e fibers pass bet!een bundles of corticospinal tract fibers" an associated contralateral hemiparesis !ould also locali=e the lesion to the pons. What if instead of associated diplopia or contralateral arm and leg !eakness" the patient complains of hearing loss and tinnitus7 %his suggests in$ol$ement of the auditory ner$e. %he t!o places that the facial ner$e is in close pro&imity to the auditory ner$e are !ithin the cerebellopontine angle F Fi2.$# *G and !ithin the temporal bone. f !e !anted to" !e could locali=e a V ner$e lesion e$en more precisely in terms of !here the lesion is in relation to the departure of the ner$e to the stapedius muscle" the chorda tympani" and the greater superficial petrosal ner$e Fbased on the presence or absence of hypersensiti$ity to sound" loss of taste" and impaired lacrimation" respecti$elyG. Why bother doing this7 t is not a simple e&ercise in mental masturbationS rather it is an e&ercise that allo!s us to begin to address etiology. %he pathophysiological processes underlying an intrinsic pontine lesion Fe.g." $ascular or demyelinating diseaseG differ from those underlying a cerebellopontine angle lesion Fe.g." tumorG" !hich differ from those underlying a peripheral facial ner$e lesion Fe.g." trauma" infection" or idiopathicG.
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Fi2.$# 7! A=ia" s#'tio, th$o.2h o,s at "#+#" o) )a'ia" ,.'"#.s!
Fi2.$# *! CN VII a,/ CN VIII at '#$#b#""oo,ti,# a,2"#!
Path+h$(l)$ n neurology" a patient:s dysfunction is not only the e&pression of !here the disease occurs" i.e." a consideration of !hich crosssection of circuits is do!n" but also a reflection of the particular disease process causing the disability. ' neoplasm" an infarct" and demyelination in the right frontal lobe !ill all cause leftsided !eakness" but at different rates Ftime intensity profileG and !ith different indi$idual features Fheadache" sei=ures" papilledema" episodic !a&ing and !aning" aggra$ation by heat" etc.G. T"e2nten(t$ Pr*le So the next step in neurological diagnosis is to interpret temporal features of the patient’s symptoms in terms of pathophysiological principles. 3ou need to kno! !hat the $ery first symptom !as. Patients often pick the most
dramatic e$ents and play do!n earlier subtle details. *on:t let them. 'sk for earlier" perhaps less ob$ious symptoms of the same thing. Warning signs. 'sk if they !ere absolutely 1<
;5
:! R#'.$$#,t$#mitt#,t9 episodic attacks of symptoms !ith rapid reco$ery to normal health. %his implies repeating episodes of a single process as occurs !ith transient ischemic attacks F%'G" sei=ures" migraine" and multiple sclerosis. n the case of sei=ures" migraine" and often %'s" the symptoms are highly stereotypical. n the case of multiple sclerosis" symptoms $ary depending on the lesion site" and the process may e$ol$e to a secondarily progressi$e one in !hich there is only partial reco$ery from each attack. 8! Ch$o,i'1$o2$#ssi+#9 months to years. %his implies gradual deterioration as occurs !ith degenerati$e diseases like 'l=heimer:s dementia" /untington:s chorea" etc.
S$"+t" t$+e( can also pro$ide a clue as to pathophysiology9 7! N#2ati+# s-mtoms. Beduction F!eakness" numbnessG or complete loss Fparalysis" analgesiaG of function. mplies at least partial or complete failure of impulse conduction in a functional system. %his can be re$ersible Fe.g." %'G or irre$ersible Fe.g." infarctionG. *! Positi+# s-mtoms. #&aggeration of a physiological phenomenon. %hese can be brief and $ery intenseparo&ysmal Fas in epileptic sei=uresG or episodic and recurrent Fas in hemifacial spasm or trigeminal neuralgiaG. %hese e&les imply abnormal e&cessi$e discharges in gray matter or ephaptic e&citation in a fiber path!ay and are considered irritati$e. Positi$e symptoms can also be slo! and continuous9 chorea" dystonia" nystagmus" tremor. /ere positi$e symptoms imply chronic imbalance in comple& integrated motor path!ays" perhaps reflecting the effect of degeneration or remo$al of one component part. :! S#'o,/a$- s-mtoms. -ymptoms referable to mass effect. ' lesion Fe.g." tumor" infarctG causes primary symptoms by local destruction and secondary symptoms as the lesion gro!s through de$elopment of edema" pressure on ad?acent brain Fne!" more se$ere symptomsG" herniation Fstupor" coma" midbrain signsG" blockage of C-4 path!ays Fpapilledema" stuporG" and stretching of $essels and meninges Fheadache" stiff neckG. 8! (#ha+io$a" s-mtoms. Comple& changes in personality and beha$ior. ccasionally these can be described as dementia" depression" or temporal lobe sei=ures. 'lthough comple&" disorders of perception Fneglect and denialG" motor beha$ior Fapra&iaG" language Fmutism" aphasiaG or mood can usually be approached by the same step!ise method used for any neurological dysfunction. n these cases" ho!e$er" it is imperati$e to inter$ie! relati$es" neighbors" or other independent obser$ers to obtain the historical data. ut the process is the same9 symptom analysis" anatomy" pathophysiology.
Etl)$ *etermination of etiology is the last step in neurological diagnosis" occurring after lesion locali=ation and consideration of pathophysiology. nce the patient+s symptoms" illness time course" demographic factors Fage" se&" occasionally ethnicityG" risk factors" and other medical conditions are put together !ith the e&am findings and predicted anatomical locali=ation" you !ill disco$er that the etiological possibilities are reduced to ?ust a fe!. f this stepbystep diagnostic method is not follo!ed" on the other hand" you !ill be left !ith a long list of remote etiologies. Categories of etiology in neurological disease are similar to those of nonneurological disease genetic" congenital" infectious" immune" endocrine" metabolic" to&ic" traumatic" $ascular" mechanical" neoplastic" degenerati$e" psychological e&cept for the addition of demyelination" epilepsy" and migraine in neurological disease.
Pre(entatn * the Patent 7th Ne%rl)al D(ea(e (oing through the abo$e process of locali=ation !ill be essential to you as a third year student on Neurology and as a physician !ho encounters any patient !ith neurological complaints. %he neurological /IP is structured to reflect this by e&panding on the 'ssessment section that is common to all other areas of medicine. Whene$er you present or !rite up an /IP on a patient !ith neurological disease" your history and e&am should al!ays be follo!ed by a paragraph consisting of 576 a brief summary of the patient:s history and e&am findings" 5*6 a statement about anatomical locali=ation" 5:6 the diagnosis" and finally 586 the management plan. %he b$i#) s.mma$- o) histo$- a,/ #=am ser$es t!o purposes9 to distill all the information you ha$e collected on the patient into the essential facts and to re$ie! the highlights of your presentation for any listener !hose mind may ha$e been !andering. t should include the patient:s age" gender" any rele$ant past medical history" symptoms Fincluding a time course for themG" and e&am findings. %his is the time you should use !ords such as rapidly progressi$e or in a step!ise fashion o$er the past 6 months to describe the timeintensity profile and the time you can use medical terminology to V6.15.11
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interpret the patient:s symptoms and e&am findings. 'n e&le9 3ou report that your 6yearold female patient !ith a history of asthma" hypertension" diabetes" renal insufficiency" and tubal ligation complains of !aking up this morning !ith blurred $ision and seeing t!o of e$erything e&cept !hen she looks to the left. 3ou report on the e&am that the patient has limitation of abduction of the right eye" an increase in the separation of the t!o images !hen looking to the right" $ibratory loss at the great toe bilaterally" and retinopathy. 3our summary statement !ould be something like" ased on the patients age, symptom time course, lac8 o! preceding trauma, and lac8 o! associated neurological or systemic abnormalities, other causes o! sixth ner"e palsy such as trauma, intracranial tumor, multiple sclerosis, meningitis, and giant cell arteritis would be exceedingly unli8ely.< %he ma,a2#m#,t "a, then discusses ho! you intend to rule out or rule in potential diagnoses and the treatment you !ill offer.
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Performing a Lumbar Puncture on Neurology 1. 2. ;. . 5. 6.
2. ;. . 5.
6. E.
J. K. 1<. 11. 12. 1;. 1. 15. 16. 1E. 1J. 1K. 2<. 21. 22. 2;. 2. 25. 26.
Check coags)plts" NB Z 1.5" plts [ 5<" don+t forget about the P%%. @ake sure there is no risk of herniation Flook for papilledema and check the /C%G. btain consent" place it in the chart" and e&plain the procedure to the patient. (i$e V 'ti$an to an&ious patients. btain a DP kit. (ather !hat is not in the DP kit9 a. sterile glo$es Fbring an e&tra pairG b. nonsterile glo$es c. pen d. e&tra lidocaine Fonly 2mD is in the kitS !rite an order for either a 1L or 2L 5mD bottle" and ask the nurse to get it out of py&isG e. sprotte needle f. betadine g. plenty of e&tra & gau=e. h. chuck pad i. sterile to!els FoptionalG ?. yello! face mask Place the yello! sticker from the DP kit on the card inside the red binder at the nurses station. Place all e8uipment on a food tray table" !ith a trash can at arms length. 'd?ust the height of the bed to your comfort le$el. Positioning is key. f opening pressure is needed" the patient needs to be in the lateral decubitus position. ther!ise DPs can be done sitting up much more easily" particularly for the obese. f sitting up" ha$e the patient rest his)her legs on the side of the bed" then ha$e them lean o$er the food tray table. Wash your hands. Put on your nonsterile glo$es. @ark !ith your pen the e&act location !here you !ill insert the spinal needle. %he superior iliac crest lines up !ith the D spinous process. With the pad of your thumb you should be able to simultaneously feel both the spinous process and the interspace. (et a feel for the interspace along both the $ertical and hori=ontal plane. 'l!ays make your first attempt at DD5 before mo$ing up to D;D. %uck the chuck pad under the patients back and buttocks so the betadine !ill not get on the bed. pen the DP kit and the sterile glo$e packet. pen the betadine bottle and pour into the reser$oir inside the kit. @ake sure you s8uirt a!ay from yourself. etadine !ill stain and ruin your clothes. pen the top of the lidocaine bottle Fthe larger one that did not come !ith the kitG and place on the outer sterile !hite co$ering that surrounds the kit. @ake sure to not touch the top of the bottle !ith your nonsterile hands. pen up the e&tra gau=e packets and drop them into the sterile field. Put on your face mask. Put on the sterile glo$es. >nscre! the caps of all of the C-4 collection tubes and place them in order that they are to be collected. -et up the manometer and turn the stopcock 1Jsing all of the pink sponges in the kit" apply betadine in concentric circles. %ake a large piece of gau=e from your sterile field and use it to pick up the nonsterile lidocaine bottle *ra! lidocaine into the syringe. Clean off the betadine directly abo$e the chuck and the patient+s back !ith a sterile piece of gau=e. %here are t!o sterile drapes in the DP kit. %ake the tape off the blue drape Fthe one !ith a s8uare in the middleG" and stick it directly on the patient+s back !here you ha$e ?ust remo$ed the betadine. -lightly fold the blue drape so the middle s8uare is not e&posed. %his drape !ill lie o$er the chuck and !ill ser$e as a sterile area !here you can rest your hands. Place the !hite sterile drape o$er the iliac crest" this !ill allo! you to find your interspace !hile still remaining sterile. n the interim the patient has likely mo$ed and the markings you ha$e pre$iously made !ith your pen !ill no longer be accurate. 4ind your spot once again. 'pply lidocaine to the e&act spot o$erlying the desired interspace. Cut the skin !ith the needle included in the sprotte needle packet.
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2E. Beconfirm the spot of the inter$ertebral space. >se your nondominate thumb as a guide" ha$ing the middle aspect of the pad of your thumb on the spinous process" and the tip of your thumb simultaneously pressing deeply into the interspace. 2J. %he needle should be inserted immediately ad?acent to the tip of your thumb" at 15 degrees cephalad" as if aiming at the patient+s umbilicus. 2K. %he needle !ill pass through" in order" the skin" subcutaneous tissue" supraspinous ligament" interspinous ligament bet!een the spinous processes" ligamentum fla$um" epidural space Flocation of the internal $ertebral $enous ple&usG" dura" arachnoird" and into the subarachnoid space bet!een the ner$e roots of the cauda e8uina. ;<. 's the needle passes through the ligamentum fla$um" you may feel a popping sensation. ;1. f attempt is unsuccessful and bone is encountered" !ithdra! the needle to the subcutaneous tissue" !ithout e&iting the skin" and redirect the needle. @ake sure the stylet is hubbed against the needle !hene$er you pull out and redirect. ;2. nce you are in the space" !ithdra! the stylet in 2mm inter$als to assess C-4 flo!. f flo! is poor" you may rotate the needle K< o" since a ner$e may be obstructing the opening. ;;. f the tap is traumatic" the C-4 may be tinged !ith blood. %he blood should clear as additional C-4 is collected" unless the source of the blood is a subarachnoid hemorrhage. f you encounter frank blood and you are uncertain of being in the subarachnoid space" you ha$e probably hit a $ein in the internal $ertebral $enous ple&us. Pull out the needle and redirect. ;. >se the fle&ible tube to connect the manometer Fstopcock already turned to!ard youG to the hub of the needle. ' measurement can be made after the column of fluid stops rising. ;5. 'fter measuring the opening pressure" turn the stopcock 1J< o to!ard the patient so the C-4 in the manometer can be collected in your first tube. ;6. Bemo$e the manometer and collect ; cc of C-4 in each tube. \1< cc should be collected for either cytology or %rotter studies. ;E. Put the stylet back into the DP needle and remo$e the needle. @ake sure the stylet has not been contaminated. ;J. etadine left on the patient+s body is irritating to the skin. %horoughly clean the betadine off the patient+s back by using hand foam and paper to!els. ;K. Write a procedure note in Compass. Print it" sign it" and place in chart. f someone super$ised" they need to !rite an addendum to that effect and also sign it. <. Dabel all tubes. 'll labels must be initialed and dated)timed by you. 1. Write order for labels to be made" or make up re8uisitions yourself. Cytology re8uires a different form. 2. Ha,/ /#"i+#$ all C-4 to the lab.
4ollo!ing are the labs !here each study goes. 3ou !ill need to send separate tubes to each lab" but you can get multiple labs on the same tube if they are going to the same place Fe&cept separate cell countsG. Call 21E< or 211
T.b# 1I 2 or ; 2 or ; 2 or ; 2 or ; 2 or ; 1 or 2 or ; 2 or ; 'ny 2 or ;
Lo'atio, /ematology Chemistry @icrobiology Chemistry @icrobiology Chemistry /ematology Chemistry Chemistry -urgical Pathology Chemistry" *on+t forget special form]]] N@ 'ntibody 2 or ; Chemistry 4lo! cytometry 'ny /ematology ] Cytology can only be done on !eekdays before ; pm.
*N+% 4B(#% % B#T>#-% % -'V# ' %>#0
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Neurological /istory and #&am a,/ th# N#.$o"o2i'a" W$it#1. N#.$o"o2- C"#$%shi A""-so, >a;."ia MD a,/ Ma$% Go"/b#$2 MD R#+is#/ 0
's you !ere instructed in your preclinical years" do not skimp on the neurological history0 With a carefully obtained history" it is not uncommon to be able to make a diagnosis before you e$en take out your refle& hammer and tuning fork^ thus the commonly 8uoted saying that if you ha$e one hour to do an /IP" 5< minutes should be spent on the history and 1< minutes on the e&am. 1G *ocument a careful chronological history of the patient+s symptoms. -tart !ith the $ery first symptom and !ork for!ard from there. Bemember that patients often pick the most dramatic e$ents and play do!n earlier subtle details. *on:t let them. Hno!ing !hat occurred first allo!s for kno!ing ho! and !here the illness started. 'sk patients for earlier" perhaps less ob$ious symptoms. 'sk them if they !ere absolutely 1<
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;G >se the patient+s o!n !ords" but be sure you understand !hat those !ords mean to the patient. *o not substitute your !ords for the patient+s^!riting hemiplegia instead of !eakness on my left side adds little to the accuracy of the information and in$ites error in interpretation. -imilarly" do not accept another doctor+s diagnosis or interpretation" !hich patients often like to gi$e you in place of details about their actual symptoms. !as di==y last !eek. @y doctor said it must ha$e been my blood pressure. ut don+t simply accept the patient+s o!n !ords !ithout clarifying !hat those !ords mean to the patient. 3ou must insist on a detailed description of symptoms so that you can be sure the t!o of you are on the same !a$elength. 3ou !ould be surprised !hat some patients actually mean !hen they say they ha$e numbness or di==iness. With further 8uestioning" di==y may be described as my head !as s!immy" and !ith still further 8uestioning" refined to things spinning around like !hen you get sea sick. %his is much more useful" as it suggests $ertigo rather than lightheadedness or unsteadiness. 3ou can set aside your /olter monitor and tilt table test and focus on causes of labyrinthine dysfunction. G -ince neurological illness may affect the patient+s le$el of consciousness" ability to attend" or cogniti$e function" sometimes it is necessary to in$ol$e family members or !itnesses in history taking. f you see a patient !ho !as found do!n and has no memory for !hat happened" it is imperati$e to speak !ith somebody !ho !itnessed the e$ent. 4inding out that the patient complained of an e&cruciating headache prior to losing consciousness or that there !as ?erking of his right face and arm ?ust prior to his falling to the ground is indispensable information. St#s to A$oa'hi,2 th# N#.$o"o2i'a" E=ami,atio, G#,#$a" 'o,si/#$atio,s 1G 'fter only a limited e&posure to the neurological e&am in your first and second year course!ork" it is to be e&pected that the e&am !ill still take you a long time to do. -peed should not be your goal. 3ou !ill be e&pected to perform a relati$ely complete neurological e&am on your initial e$aluation of all patients. n the case of stable patients !ith clear diagnoses" you may be able to perform a more focused e&am Ffocusing on those e&am tests rele$ant to the patient+s particular complaintsG on subse8uent e$aluations. ut this is not appropriate if the diagnosis is unclear or if there is any concern for the de$elopment of ne! findings due to the disease process or your team+s inter$entions. f in doubt" discuss it !ith your resident.
2G Bemember that e$en doctors !ho are proficient at the complete neurological e&am perform certain parts of the screening e&am on all patients. n a patient !ho has no neurological complaints" you are looking for une&pected findings that may lead to an early diagnosis and possibly treatment of a presymptomatic disease" ?ust as you !ould do by listening to a patient+s lungs e$en if he has no pulmonary symptoms. r you may find neurological abnormalities that point to!ards a specific cause for a systemic disease. 4or patients !ith specific neurological complaints" the goal is to test your hypotheses about the nature of the patient+s illness. 3ou should perform not only those tests that !ill support your hypothesis" but also those tests that !ill refute it. 4or e&le" !eakness may be due to a lesion any!here !ithin the neuroa&is from the cerebral corte& do!n to the muscle. 4inding associated hyperacti$e refle&es and e&tensor plantar responses gi$es you $ery different information Fupper motor neuron dysfunctionG than finding hypoacti$e refle&es" atrophy" and fasciculations Flo!er motor neuron dysfunctionG. 'nd if you e&amine only the muscles and refle&es and ignore the sensory e&am because the patient has no sensory complaints" you may miss $ital clues to the diagnosis9 the presence of associated sensory deficits e&cludes isolated muscle or neuromuscular ?unction disease. ;G ' great deal of information can be learned about the patient+s neurological function by simple obser$ation. *oes he s!ing his arms symmetrically !hen !alking into your office7 *oes she interact !ith you !hen you stand on the right side of her bed" but ignore you !hen you stand on the left7 s the sole of one of his shoes !orn and the other not7 @uch of the mental status e&am can be completed during history taking. 'sking a patient his name as part of a test of orientation may be needless and insulting !hen he ?ust finished gi$ing you a coherent" detailed chronological description of his illness. G %he neurological e&am can be organi=ed into E categories9 F1G mental status" F2G cranial ner$es" F;G motor system" FG refle&es" F5G sensory system" F6G coordination" and FEG station and gait. t !ill help if you approach the e&am systematically and establish a routine. -ome people prefer the standard order listed abo$e. @any test gait first. thers like to !ork from head to toe. %here is no right !ay to do it" as long as you co$er all the categories and keep your patient+s comfort in mind Fe.g." minimi=e the number of times he needs to mo$e from the supine to the seated or standing positionG. *uring the course of the e&am pay attention to the distribution of abnormalities Fpro&imal $s. distal" arms $s. legs" left $s. rightG.
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M#,ta" Stat.s n addition to its $alue in helping to locali=e lesions" the mental status e&am is re8uired to establish the reliability of the rest of your e&am. 3ou must determine that the patient is alert" attenti$e" oriented" cooperati$e" and not debilitated by depression or psychosis before you can appropriately interpret other e&am findings. f a patient is se$erely inattenti$e" he may fail to follo! commands" mistakenly leading you to diagnose aphasia. f he is uncooperati$e and combati$e" your sensory e&am !ill likely be unreliable. F%his does not mean you cannot do any sensory e&am" ?ust that you !ill ha$e to substitute techni8ues that do not rely on cooperation" i.e." response to pain.G a. De$el of a!areness9 e.g." a!ake and alert Ff not alert" 8uantify !ith statement of stimulus re8uired to e$oke response" e.g." $oice" touch" painG b. 'ttenti$eness9 s the patient paying attention to you and your 8uestions or is he distractible and re8uiring re focusing7 %est !ith serial Es" WBD* back!ards" counting back!ards" saying months back!ards c. rientation to self" place" time FBemember that disorientation to time typically occurs before disorientation to place or person and that disorientation to self is typically a sign of psychiatric disease.G d. -peech I language9 fluency Fdoes patient speak spontaneously in full sentences !ithout hesitation7G" repetition Fe.g." !ent to the store and forgot my !alletG" comprehension Fis the patient able to follo! a 1" 2" or ;step command7G" reading Fa !ritten commandG" !riting Fa complete sentenceG" naming Fob?ects around the room" including parts of ob?ectsG e. @emory9 includes registration and retention i. mmediate recall F!hat did ?ust say to you7G9 %est !ith ; ob?ects Fe.g." apple" table" pennyG" digit span ii. Becent9 current e$ents" home address" !hat !as eaten for breakfast iii. Bemote9 date of birth)marriage" military e&perience" birthplace" presidents f. /igher intellectual function9 general kno!ledge" abstraction" ?udgment" insight" reasoning g. @ood and affect %he primary purpose of assessing mood and affect in the neurological e&am is to determine if psychiatric disease may be interfering !ith the neurological assessment. C$a,ia" N#$+#s %he cranial ner$es consist of ner$es that e&it through foramina in the skull" not necessarily ner$es that originate in the brain Fthough most doG. %he follo!ing table lists the $arious testable functions of each of the cranial ner$es. %he functions in bold are those that should be tested in a screening e&am. cannot stress enough the importance of the fundoscopic e&am in all patients from the standpoint of both the general physical e&am and the neurological e&am. Visual acuity is certainly a $ital part of the general e&am" but did not include it as $ital in the screening neurological e&am because the $ast ma?ority of impairment in $isual acuity is due to refracti$e errors rather than optic ner$e dysfunction.
" V" V V V V "
#&amination -mell Fuse coffee" lemon" $anilla" etcS a$oid peppermint" menthol" and ammonia since they may stimulate taste buds or trigeminal ner$e endings and do not specifically test smellG Vis.a" )i#"/s o'."a$ ).,/i" $isual acuity F-nellen chartG E-# mo+#m#,ts .i""a$- $#a'tio, to "i2ht and accommodation" con$ergence Fa'ia" s#,satio," ?a! mo$ements" corneal refle& Fafferent limbG Fa'ia" mo+#m#,ts@both so,ta,#o.s a,/ to 'omma,/ Fraising eyebro!s" closing eyes" smilingG" taste Fe.g." salt" sugar" lemonG H#a$i,2 Ffinger rub or !hisper^not tuning forkG Pa"at# mo+#m#,t" pharyngeal sensation" $oice" s!allo!ingS gag not usually necessary Sh$.22i,2 sho."/#$s t.$,i,2 h#a/ a2ai,st $#sista,'# To,2.# ositio, a,/ mo+#m#,ts
Please note that !hile the abo$e table lists the $arious testable functions of each of the cranial ner$es" some of the tests are rarely performed in routine practice because 1G their absence does not necessarily pro$ide useful information Fe.g." sense of smell and taste may be absent or reduced in the setting of an upper respiratory infectionS gag refle& is absent in many hospitali=ed patients as !ell as normal elderly patientsG or 2G testing multiple functions of a particular cranial ner$e may not add ne! information Fe.g." if pupillary reaction to light is present" then assessing pupillary reaction to accommodation does not gi$e any ne! informationG. 'gain" though" you need to kno! how to perform these tests in the e$ent that they are rele$ant to the patient+s complaints or illness. lfaction must be assessed if the patient complains of a disturbance in taste V6.15.11
2
or smell or if a lesion of the olfactory groo$e is suspected. -imilarly" taste should be assessed !hen there is a pertinent complaint Fthough the complaint usually turns out to be due to loss of smellG. Pupillary response to accommodation must be assessed if the pupils do not react to light. Corneal refle& must be tested if the patient complains of sensory disturbance in the face Fbecause it is an ob?ecti$e indication of trigeminal ner$e dysfunction !hereas sensory complaints are sub?ecti$eG or if the patient is comatose Fbecause you cannot ask the patient if facial sensation is symmetricG. /o!e$er" repeatedly brushing a !isp of cotton across the eye can potentially scratch the cornea" so you don+t need to be checking a corneal refle& e$ery day on your patient !ith facial numbness. 'dditional points9 %he best !ay to test $isual fields is to co$er one of the patient+s eyes and mo$e a finger or penlight into the periphery of each 8uadrant" asking the patient to indicate !hen mo$ement is detected. 4ailing to test each eye indi$idually risks failing to differentiate a deficit present in one eye from that present in both eyes. /a$ing the patient report the number of fingers you are holding up in both of your hands simultaneously re8uires not only $isual field function but also language and calculationS thus you may erroneously diagnose a $isual field deficit in the presence of impairment of one of these functions. 4or the fundoscopic e&am" tell the patient to fi& $ision on a distant target" and be sure that your head is not obstructing the patient+s $ie! of that target. Bemember that the temporal edge of the optic disc is usually 8uite sharp" but the nasal edge is sometimes not so distinct. Visuali=ing $enous pulsations can be good e$idence of normal intracranial pressure. 4or $isual acuity testing" use a manufactured Fnot a photocopiedG -nellen chart for near $ision. %he chart should be held at the distance specified on the card. 'ny glasses should be kept on" and the patient should close one eye and read the smallest line possible. Push patients to keep reading smaller lines^e$en if they say they can+t^until they make more than 2 errors in a line. Normal pupillary si=e is about 25 mm. *escribe si=e" e8uality" and if there is any irregularity. %est the pupillary light reaction in a dark room. /a$e the patient fi& $ision on a distant target in order to eliminate the effects of accommodation. Pay attention to both the direct Fsame eyeG and consensual Fopposite eyeG response. #&traocular mo$ements should be tested in all si& cardinal directions of ga=e Fa big /G. oth smooth pursuit Fsmooth follo!ing mo$ementsG and saccades Fdiscrete" rapid mo$ements from one ob?ect to anotherG should be assessed. 3ou should kno! the boundaries of the trigeminal sensory distribution. V1 e&tends far back to the top of the skull^it does not end at the hairline. V; ends ?ust abo$e the ?a! line inferiorly and ?ust before the ear laterally. 'ssessment of cranial ner$es and in$ol$es e&amining palate mo$ement !ith phonation. ' nucleus ambiguous lesion !ill result in a lo!er palate ipsilaterally. *o not focus on the u$ula" !hich can de$iate to one side or the other in the normal person. (ag need only be tested if the patient+s complaints suggest a cranial ner$e or lesion or if the patient is comatose and the palate cannot be assessed. -ternocleidomastoid strength is tested by placing your hand on the patient+s ?a! and ha$ing the patient rotate the head to!ards your hand. With this maneu$er" you should be able to see and feel contraction of the opposite -C@.
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Moto$ #=am %he motor e&am is affected not only by muscle strength" but also by effort" coordination" and e&trapyramidal function. %ests of de&terity and coordination are most sensiti$e to picking up upper motor neuron and cerebellar abnormalities !hereas direct strength testing is more sensiti$e to lo!er motor neuron dysfunction. ther important aspects of the motor e&am include assessment of muscle tone Fe.g." spastic" rigid" flaccidG" patterns of muscle atrophy or hypertrophy" disturbances of kinesis Fe.g." the hypokinesia Xpo$erty of mo$ementY and bradykinesia Xloss of speed and spontaneity of mo$ementY of parkinsonismG" and endurance of the motor response Fe.g." the fatigability of myasthenia gra$isG. With regard to muscle strength testing" there are se$eral points to remember. 4irst is the importance of proper positioning. %he limb must be positioned in such a !ay as to permit the muscle being e&amined to act directly and to a$oid as much as possible the recruitment of other muscles ha$ing similar function Fe.g." biceps and brachioradialisG. %he pro&imal portion of the limb must be fi&ed !hen mo$ements of distal muscles are being tested. %he humerus should be fi&ed !hen testing pronation so that the patient is unable to use his shoulder to compensate for !eak pronation. Weakness of grip may be erroneously diagnosed if the !rist of a patient !ith radial ner$e palsy is not placed into a position of !rist e&tension. -econd" al!ays gi$e yourself the ad$antage !hen testing indi$idual muscle strength. 4or e&le" test the iliopsoas by pushing do!n on the !oot of the outstretched leg rather than on the thigh. *o not be afraid to push hard0 #$en more subtle !eakness can be detected by ha$ing the patient !alk on toes Fankle plantar fle&ionG and heels Fankle dorsifle&ionG and do a knee bend Fpredominantly iliopsoasG. %hird" be a!are of normal $ariability in strength based on age" se&" handedness Fi.e." the muscles on the dominant side are usually strongerG" and muscle Fe.g." in a patient !ith normal strength" you should ne$er be able to o$ercome the ankle plantar fle&ors but you !ill likely be able to o$ercome the abductor digiti minimiG. 4ourth" placing a hand on the muscle being tested can confirm !hether effort is consistent. f you belie$e the patient is gi$ing subma&imal effort Fe.g." due to painG" encourage ma&imal effort for at least a second. G$a/#
< 1 2 ; 5
D#s'$itio, No muscular contraction arely detectable muscle contraction 'cti$e mo$ement)strength present 'cti$e mo$ement)strength against gra$ity 'cti$e mo$ement)strength against gra$ity I against some resistance Normal muscle strengthS acti$e mo$ement against full resistance
]Note9 Q or after the number may be used to further distinguish bet!een items on the scale 3ou should kno! ho! to test the follo!ing muscles9 >pper e&tremity9 1. *eltoid^abduction Fele$ationG of upper arm FC56" a&illary ner$eG 2. iceps^fle&ion of forearm at elbo! FC56" musculocutaneous ner$eG ;. % . riceps^e&tension of forearm at elbo! FC6J" radial ner$eG 5. #&tensor carpi radialis^dorsifle&ion of hand at !rist FC56" radial ner$eG 6. 'bductor pollicis bre$is^palmar abduction of thumb F!ith thumb at right angle to palmG FCJ%1" median ner$eG E. nterrosei^finger abduction FdorsalG I adduction FpalmarG FCJ%1" ulnar ner$eG Do!er e&tremity9 1. (luteus ma&imus^hip e&tension FD5-2" inferior gluteal ner$eG 2. liopsoas^hip fle&ion FD1;" femoral ner$eG ;. Tuadriceps^knee e&tension FD2" femoral ner$eG . /amstrings^knee fle&ion FD5-2" sciatic ner$eG 5. %ibialis anterior^foot dorsifle&ion FD5" deep peroneal ner$eG 6. (astrocnemius)soleus^foot plantar fle&ion F-12" tibial ner$eG
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R#)"#=#s Befle& testing is important because it is the most ob?ecti$e part of the neurological e&am" it is the least dependent on cooperation Fbut note that refle&es can be reinforced or decreased $oluntarily to some e&tent" as occurs in guardingG" and it may pro$ide an early indication of neurological dysfunction. %he muscle stretch refle&es are obtained by placing the muscle in slight tension" tapping the tendon or the periosteum to !hich the muscle is attached" and obser$ing the $igor and briskness of the response. @uscle contraction should be seen and felt. Pay attention to any asymmetry bet!een right and left. f refle&es are brisk" try to bring out subtle asymmetry by using the lightest tap that !ill elicit the refle&. f refle&es are diminished or absent" try reinforcing the refle& by distraction or ha$ing the patient contract other muscles Fe.g." clench teethG. Note" ho!e$er" that symmetrically brisk" diminished" or e$en absent refle&es may be found in normal people. %he superficial FcutaneousG refle&es are elicited by applying a stimulus to either the skin or mucous membranes and include" among others" the superficial abdominal" cremasteric" anal" and plantar refle&es. Plantar refle&es are often considered to be the most important test in the neurological armamentarium because an abnormal response Fi.e." e&tensor plantar response" abinski sign" upgoing toeG is a specific indicator of corticospinal tract dysfunction and may be the only sign of ongoing disease or the only residual sign of pre$ious disease. G$a/# < 1Q 2Q ;Q Q
D#s'$itio,
No response *iminished response Normal)a$erage response risker than a$erage response @arkedly hyperacti$e" often !ith sustained clonus Frhythmic oscillations of fle&ion)e&tensionG and)or spreading to other muscles
3ou should kno! ho! to test the follo!ing refle&es Fner$e root in bold is the predominant contributorG9 1. iceps FC5" C0S musculocutaneous ner$eG 2. %riceps FC6" CS radial ner$eG ;. Hnee FD2" D;" L8S femoral ner$eG . 'nkle FS7" -2S tibial ner$eG S#,satio, %he sensory e&am can be frustrating at times because of its sub?ecti$e nature and reliance on cooperation. t is prudent to test sensation early in your e&am if you anticipate poor cooperation to be a factor. #&plain to your patients !hat you are going to do and !hat you e&pect of them" then ha$e them close their eyes for the testing. e a!are of the fact that patients may report differences in sensation in the presence of normal sensory function because of actual differences in the stimulus intensity applied^you are not a machine and cannot apply identical pressure each time you poke !ith a pin.
oth superficial and deep sensation should be tested in all four limbs. 'l!ays compare sidetoside" asking" 're these about the same7 rather than leading 8uestions like" s this sharp7 or Which is stronger7 Bemember that thresholds for detecting a stimulus are $ery lo! in distal or hairco$ered areas and higher o$er thick skin. -uperficial sensation Fpain and temperatureG is mediated by unmyelinated and small myelinated ner$e fibers $ia the spinothalamic tract. Pain sensation can be tested !ith a safety pinS temperature sensation can be tested !ith a cool metal ob?ect Flike a tuning forkG. n the patient complaining of sensory symptoms" demonstrate !hat the pin)temperature should feel like in an unin$ol$ed area. -ince the boundary bet!een dull and sharp or !arm and cool is usually more readily percei$ed by the patient if you mo$e your stimulus from the abnormal area to the normal area rather than $ice $ersa" asking the patient to report !hen the stimulus begins to feel stronger is the best !ay to identify the margins of a hypesthetic area. -ometimes it is useful to apply the stimulus to an unin$ol$ed part of the body and say" f this sharpness)coolness is !orth `1" ho! much is this !orth7 and then apply the pin)cool ob?ect else!here. *eep sensation Fpressure" position sense" and $ibrationG is mediated by large fibers $ia the dorsal and lateral columns. Vibration and position sense FproprioceptionG should be tested at the most distal ?oint of the limb. f sensation at this ?oint is impaired" increase the intensity of the stimulus and)or mo$e pro&imally. #mphasis should be on the toes and feet" !here the longest" large myelinated fibers are most likely to be impaired. %he appropriate tuning fork to use in testing $ibration is 12J/=. 3ou should kno! your o!n tuning fork perception and the usual time it takes to fade a!ay. ut there are no absolutes for ho! long a normal person should be able to feel a $ibratory stimulus at a particular ?oint because this is dependent on ho! hard you strike the tuning fork" the patient+s age" etc. t is most important to compare sidetoside perception. 4or position sense testing" stabili=e the ?oint !ith one hand and a$oid a pushpull stimulus that lets the patient cheat. 4or e&le" in the great toe" steady the interphalangeal ?oint !ith one hand and hold the sides of the distal phalan& !ith the other to mo$e it up and do!n. @ake V6.15.11
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sure the patient understands the only choices are up or do!n^there is no side!ays or middle. Normal thresholds should be no more than 2 or ; degrees. %here is a third category of sensation" integrati$e sensation" !hich re8uires higher le$el processing of the abo$e primary sensory modalities and includes such functions as stereognosis Fability to recogni=e ob?ects by touchG" graphesthesia Fability to recogni=e letters or numbers dra!n on the finger or palm G" )*point discrimination Fability to differentiate stimulation applied to the skin by one blunt point from stimulation by t!o pointsG" and constructional ability Fcopying simple and comple& forms" dra!ing a clockG. Extinction is the loss of the ability to percei$e sensation on one side of the body !hen both sides of the body are stimulated simultaneously. inger agnosia is the inability to recogni=e" name" and select indi$idual fingers !hen looking at the hands. %he Romberg test is another maneu$er that is used to detect impaired sensory input. %he patient is first asked to stand !ith the feet together and eyes open and then to close the eyes. 'n abnormal response Fpositi$e Bomberg signG is for the patient to be able to stand upright !hen the eyes are open" but to s!ay)fall !hen the eyes are closed. Contrary to popular belief" a positi$e Bomberg sign is not an indication of cerebellar disease^the patient !ith cerebellar or other motor dysfunction !ill ha$e a hard time maintaining an upright posture !ith the feet together regardless of !hether the eyes are open or closed. Bather" it is an indication of either impaired proprioception or $estibular function. FBemember there are three sensory inputs to maintain truncal stability^$ision" proprioception" and $estibular function. Patients !ith impairment of one of these systems are usually able to compensate and maintain truncal stability. %hey cannot usually compensate !hen a second system F$ision" !hen the eyes are closedG is remo$ed. 4or the screening sensory e&am" you should perform one test of superficial sensation and one of deep sensation in each limb. -ince the ma?ority of asymptomatic sensory deficits you !ill pick up are neuropathies and the ma?ority of these begin distally" testing at the most distal aspect of the limb is usually sufficient. Coo$/i,atio, a,/ 2ait %est coordination at rest and !ith action" in the trunk Fe.g." ability to maintain an erect posture !hile sitting and standingG" and in the limbs. mpairment of coordination may be detected through simple obser$ation of the patient performing routine acts such as signing his name" reaching for ob?ects" or getting onto the e&amination table. -pecific tests to look for impaired coordination in the limbs include fingertonose Fpatient alternately touches your outstretched finger and his noseG" heelkneeshin Fpatient runs the heel of one foot do!n the shin of the otherG" rapid alternating mo$ements Fpatient alternately taps the dorsal and plantar surface of one hand onto the other handG" and finger or toe tapping. n all cases" you should focus on rhythm" steadiness" speed" and precision of mo$ements. Doss of the ability to ?udge and control distance" speed" and po!er of a motor act is termed dysmetria.
%he presence of e&traneous mo$ements Fe.g." tremor" chorea" myoclonusG should be noted some!here in your /IP" !hether here or in the motor section. -ince !alking re8uires proper functioning of the cerebellum and motor" sensory" and $estibular systems as !ell as a !hole host of refle&es" assessment of gait can pro$ide important information to guide the focus of the rest of the neurological e&am. t is for this reason that many physicians like to !atch the patient !alk at the $ery beginning of the e&am. %he specific aspects of gait for you to pay attention to include body and e&tremity postureS length" speed" and rhythm of stepsS base of gait Fho! far apart the legs areGS arm s!ing Fis it symmetric7GS steadinessS and turning. %esting tandem gait F!alking heel to toeG can be helpful" though many other!ise normal elderly patients cannot perform the task. /a$ing the patient hop on each foot is a good !ay to pick up on subtle problems !ith strength or coordination. f you hop along !ith them" they !on+t feel stupid doing it. #&les of abnormal gaits include the ataxic gait " !hich is irregular" ?erky" and broad based and is due to either propriocepti$e or cerebellar dysfunction and the spastic hemiparetic gait resulting from contralateral corticospinal tract in?ury" !hich in$ol$es fle&ion of the upper e&tremity and e&tension and internal rotation of the lo!er e&tremity !ith hip hike" circumduction" and scraping of the toes on the ground. %he screening e&am must include an assessment of gait. M#,i,2#a" Si2,s Neck stiffness often accompanies the meningeal irritation of meningitis or subarachnoid hemorrhage. %his is assessed by obser$ing for palpable stiffness on either acti$e or passi$e fle&ion and e&tension at the neck. %here are a couple other meningeal signs Frud=inski+s and Hernig+sG that you may hear mentioned" but since they pro$ide no additional
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information beyond simple testing for neck stiffness" you do not need to kno! them. %esting for meningeal signs is not necessary in a screening e&am. Th# N#.$o"o2i'a" W$it#1U
3our !riteup must include the patient+s complete neurological history and e&amination. %he history section should include the standard categories9 Chief complaint /istory of present illness Past medical history @edications 'llergies -ocial history 4amily history Be$ie! of systems Chi#) Com"ai,t %he chief complaint should be a brief summation of !hy the patient came to the hospital. -ome attendings e&pect this to be in the patient+s o!n !ords. /o!e$er" in neurology this is fre8uently impossible and sometimes it is not informati$e. t is sufficient to describe the primary symptoms^!ithout interpreting them or adding medical ?argon^and the time course.
This is a 02*year*old man with bac8 pain and progressi"e di!!iculty wal8ing o"er three wee8s.
f the source of the history is not the patient" it is appropriate here to say ho! the information is deri$ed. Source+ Since the patient was unable to spea8 on admission, the history was obtained !rom his wi!e and re"iew o! the outside medical record. HPI 3our initial sentence should indicate the patient+s handedness. %his is important for interpretation of the physical e&am Fe.g." a righthanded person !ould be e&pected to ha$e better de&terity !ith the right handG and for lesion locali=ation Fe.g." a lefthanded person may ha$e right hemisphere dominance for language" so a lesion of the left frontal or temporal lobe might not produce the e&pected aphasia in such a patientG. t is often useful to include any medical history rele"ant to the patient+s complaint in the first sentence as long as you keep it brief. ut a$oid the habit of including the entire medical history in the first breath.
The patient is a 22*year*old right*handed woman with long*standing hypertension, diabetes, and tobacco use who was standing at the 8itchen sin8 washing dishes () hours a!ter ha"ing her nec8 manipulated by a chiropractor when she suddenly de"eloped nausea, spinning sensation, and inability to !eel the temperature o! the dish water with her le!t hand.
%he remainder of the /P should chronicle the temporal course of the patient+s symptoms9 The patient reports that one day prior to admission, she saw a chiropractor !or chronic nec8 pain, who stretched and ?popped@ her nec8. She awa8ened on the morning o! admission !eeling well, ate brea8!ast without di!!iculty, and was washing dishes at 1 &M when she suddenly reali;ed that the hot water did not !eel hot on her le!t hand. She was immediately o"ercome with nausea and !elt as i! the room were spinning around her. She needed to grab onto the sin8 to 8eep !rom !alling. She staggered bac8 to her bedroom, tending to !all into the wall on her right side, and lay down to wait !or the !eeling to pass. The spinning sensation persisted regardless o! the position she was in, and she continued to !eel nauseated. &t noon, she tried to pic8 up the telephone with her right hand but 8ept reaching her hand out too !ar or too near and 8noc8ed o"er the lamp and cloc8 on the nightstand. She was e"entually able to dial A(( with her le!t hand and noticed that her "oice sounded raspy on the phone. Bpon arri"al to the emergency room at ( -M, she "omited once. 9therwise, there was no change in her symptoms.
%his first part of the /P should conclude !ith a statement of ho! the patient presented for the current admission9
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The patient4s wi!e !ound him unresponsi"e on the bathroom !loor at A+52 &M. She called A((, and the patient was transported by EMS to the >C ED.
r The patient was re!erred to the neuromuscular clinic !or !urther e"aluation o! progressi"e wea8ness.
-ometimes students are not sure ho! to organi=e the history !hen the current complaint is part of a longstanding disease process. *o you start from the $ery first manifestation of the disease e$en if it !as 1< years ago and !ork chronologically for!ard to the present day7 *o you simply state the longstanding diagnosis and then focus only on the current complaint7 ' much better solution is to first discuss the current complaint chronologically9 The patient reports that her right hand hasn4t been ?wor8ing right@ !or two days. She !irst noticed it Monday morning when she had a little di!!iculty buttoning her shirt. She was able to eat her brea8!ast and dri"e to wor8, but when she tried to sign her name on a credit card receipt at lunchtime, she couldn4t grip the pen well and her handwriting was almost illegible. She had to call her husband to pic8 her up because she couldn4t turn the 8ey in the car4s ignition. 'hen she touched that hand, the sensation seemed normal. 9n Tuesday, her hand was about the same, but she noticed some burning on urination and had a temperature o! ((, so she called her doctor and was told to go come to the hospital. and then" in a subse8uent paragraph" discuss the pre$ious manifestations of the disease9 The patient initially sought medical attention ( years ago when she awo8e with blurred "ision and noticed that when loo8ing through the right eye, light seemed dim and colors dull. She also experienced right eye pain when loo8ing to extremes o! direction. er symptoms gradually impro"ed o"er the next se"eral days without treatment and had completely resol"ed within two wee8s. Three months later, she de"eloped numbness in her legs ?li8e someone had shot them up with some no"acaine@ that started in both anterior thighs and then spread down her legs and into her !eet o"er the span o! a couple wee8s. 'ithin a !ew days, she began to ha"e di!!iculty holding her urine. She was seen at St. 7u8e4s ospital where she underwent an MRI o! the brain and spine. &ccording to the medical record, the MRI o! the brain demonstrated ) areas o! T) hyperintensity measuring F ( cm scattered throughout the peri"entricular and callosal white matter, none o! which enhanced a!ter gadolinium administration. The MRI o! the spine demonstrated a !ocal area o! T) hyperintensity in the cer"ical cord at the #=*/ le"el that enhanced a!ter gadolinium administration. She did not ha"e a lumbar puncture. She was treated with a 2*day course o! I3 methylprednisolone and had complete resolution o! her symptoms within se"eral days. She had no new symptoms until ) years ago when she started ?wal8ing li8e a drun8.@ This impro"ed a!ter another course o! steroids, but ne"er resol"ed, and she still needs to wal8 with a cane when on une"en ground or in the dar8. n this case" the pre$ious history supported the diagnosis of multiple sclerosis that the admission facesheet indicated the patient had. ut you !ould be surprised ho! many patients labeled !ith a diagnosis are passed do!n from resident to resident for years before someone finally takes a complete history and reali=es that the diagnosis !as incorrect. t is appropriate to describe medical details leading up to the current admission" including pre$ious testing" treatment" and effects of treatment. /o!e$er in most cases" reporting !hat diagnosis some other doctor ga$e the patient is unnecessary and e$en undesirable since it biases your approach to the patient. 4or e&le" saying" @r. ,ones sa! *r. ro!n !ho told him he had Parkinson+s disease is unnecessary and may steer you do!n the !rong path. ut saying" @r. ,ones has been taking -inemet for the past 6 months up to a dose of ; grams per day !ithout any impro$ement in his symptoms is $ery useful information and should certainly be included in your history. 4ollo!ing the chronological description of each problem in the /P" a ne! paragraph should include a description of the patient+s current state including disabilities9 The patient states that his :aw pain has been continuous !or the last wee8. e has been able to eat only liGuids and has lost )2 pounds in the last month. e can wal8 short distances but uses a wheelchair outside his home and reGuires assistance to dress or coo8.
4inally" the /P should include any pertinent positi$es and negati$es rele$ant to the differential diagnosis. Mr. Smith denies pre"ious episodes o! wea8ness or sensory loss. e is unaware o! any !amily members or co*wor8ers with similar problems. e denies exposure to insecticides or industrial toxins, insect bites,
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and recent tra"el. 9n !urther Guestioning he notes that he recently completed construction o! a wooden dec8 and has been using the treated scrap wood in his !ireplace.
D%"entn) the re(t * the h(tr$8 '$oid repetition. %here is no need to repeat information in the P@/ or B- that !as already stated in /P. %he social history should include information about the patient+s li$ing situation and ability to return there. *ocument !hether the patient li$es alone" needs help for acti$ities of daily li$ing" must climb steps to get to apartment" etc. %his information !ill be essential for discharge planning.
Exa" %he e&am section should include a screening general physical e&am as !ell as the se$en categories of the neurological e&am. %he general physical e&am should also address any specific areas rele$ant to the patient+s symptoms or diseases in the differential diagnosis. n the first e&le abo$e" rele$ant general physical findings !ould include the neck e&am and the cardiac e&am.
A((e(("ent an& Plan %he ne&t step is to put together the data you ha$e collected and !ork through the anatomic locali=ation of the problem" a differential diagnosis" and management plan. 3our assessment and plan should al!ays begin !ith a brie! summary of the patient+s history and e&am findings9 In summary, the patient is a 22*year*old woman with multiple cerebro"ascular ris8 !actors who had the acute onset o! nausea, "ertigo, and right hand numbness one day a!ter chiropractic manipulation. 9n exam she has a right orner4s syndrome, right*sided dysmetria, right !acial and le!t hemibody sensory loss to pinpric8, and hoarse "oice.
%his should al!ays be follo!ed by anatomic locali=ation of the process. These symptoms and signs locali;e to the right lateral medulla with in"ol"ement o! the "estibular nuclei, spinal trigeminal nucleus, sympathetic !ibers, spinothalamic tract, in!erior cerebellar peduncle, and nucleus ambiguus.
#&plain !hy other locali=ations are or aren+t possible. The lac8 o! tongue and limb wea8ness and :oint position and "ibration impairment indicates that the medial medulla is spared.
Ne&t" you should put all these data together to come up !ith the most likely diagnosis follo!ed by a short list of other possible diagnoses as !ell as ho! you are going to pro$e or dispro$e them. 6i"en the acute onset o! symptoms and the !act that the signs and symptoms are all re!erable to a speci!ic "ascular territory, the most li8ely diagnosis is a stro8e. The patient has multiple ris8 !actors !or "ascular disease, so there may be atherosclerosis o! the "ertebral artery as a source !or distal embolism. <ernati"ely, the recent chiropractic manipulation raises the possibility o! a "ertebral dissection with distal embolism. & cardiac source !or embolism is unli8ely since she has no history o! cardiac disease and has a normal cardiac exam, EH6, and chest x*ray. 9ther processes, such as multiple sclerosis and tumor, may in"ol"e the medulla, but are much less li8ely based on the patient4s age and time course o! symptom de"elopment. &n MRI scan showing restricted di!!usion in the le!t lateral medulla would con!irm the diagnosis o! acute ischemic stro8e. It may also pro"ide e"idence !or a "ertebral dissection, though angiography would be the de!initi"e test i! a dissection were not seen on MRI. Dastly" you should address the management plan. The patient will be admitted to the neurology !loor. She is not a candidate !or t*-& because her symptom onset was more than 0 hours ago. She will be started on aspirin !or stro8e treatmentstro8e pre"ention and on subcutaneous heparin !or deep "enous thrombosis prophylaxis since her mobility is impaired. >ecause o! her impaired pharyngeal !unction, she will ha"e a swallow e"aluation be!ore being permitted
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to ta8e anything by mouth. She will ha"e speech, occupational, and physical therapy. She will be counseled on smo8ing cessation. er antihypertensi"e medications and insulin will be continued, and diabetes control will be assessed with accuchec8s and a hemoglobin &I#. & cholesterol panel will be obtained. MRI o! the brain and nec8 will be per!ormed tomorrow.
3ou are strongly encouraged to use a problembased plan for initial and subse8uent notes. t is uncommon that a patient has only a single problem" and a problembased plan gi$es you a frame!ork for daily !ork.
Fr"attn) ((%e(. 3ou may !rite your note on standard chart paper or print it out on blank pages. 'side from the standard neurology forms" you may not create a ne! form for your notes. 'll notes must begin !ith the heading W>@- ; 'dmission Note or W>@- ; Progress Note. 'll notes must start !ith the date and time. f there is more than one page" number each page Fpage 2)6 etcG. -ign and date each page. f your signature is not easily legible" you should print your name as !ell. Correct errors !ith a single strikethrough and add your initials. *o not use !hiteout or erasures. Notes must be in the chart on the day of admission. t is your responsibility to ha$e your resident re$ie! and sign each note before lea$ing at the end of the day.
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St#1b-1St# G.i/# to th# N#.$o"o2i'a" E=ami,atio, A""-so, >a;."ia M!D! M#,ta" Stat.s. '. L#+#" o) 'o,s'io.s,#ss. 1. f a!ake and alert" say that. 2. f not" describe !hat le$el of stimulation is needed to arouse and keep patient a!ake. . Att#,ti+#,#ss. 1. Patient is attenti$e if able to attend to you and the e&amination !ithout getting easily distracted. 2. /a$e patient go through the months or days of the !eek back!ards or spell WBD* back!ards. Note ho! long it takes" any mistakes" perse$eration Frepeats selfG" impersistence Ffails to finishG" or getting stuckinset Fgoing for!ard instead of back!ardG. C. O$i#,tatio,. 1. When you initially introduce yourself" you should ask the patient their full name. 2. 'sk patient location Fcity" building" floorG" and full date. ;. Patient is oriented & ; if all ; are entirely correct. . f not oriented & ;" !rite out patient+s responses. *o not say oriented & 2 For 1G. *. S##'h a,/ "a,2.a2#. Disten to patient+s $erbal output9 motor ability to produce !ords" 8uantity of spontaneous speech" rate of speech production" sentence structure" accuracy)appropriateness of !ords used" and ability to repeat a sentence" follo! commands" and come up !ith the right !ords for things 1. 4luency is normal if patient speaks in complete sentences !ithout hesitancy bet!een !ords. Patients !ho are not fluent may use short" simple" and concrete sentences" and may drop modifier !ords such as ad?ecti$es. %hey might speak only !hen prompted by the e&aminer. 2. Comprehension is normal if patient is able to ans!er your 8uestions appropriately and follo! e&am instructions. a. *o !hat say9 Dook to the door and then look to the !indo!. b. f not done perfectly" gi$e simpler command9 -ho! me your thumb. c. ' threestep command that utili=es a crossed command Ftouch your right earlobe !ith your left thumbG is most sensiti$e. ;. Bepetition a. Bepeat after me9 !ent to the store and forgot my !allet. b. >se compound and comple& sentences. No ifs" ands" or buts is not a good sentence because it is nonsense. . Naming a. Point to ob?ects around room" asking !hat they are9 !atch" pen" telephone b. f done !ell" ask more difficult ones" such as the specific parts of an ob?ect9 F!atchG band" FpenG cap" FtelephoneG recei$er 5. Beading a. /a$e patient read and follo! a !ritten command9 Close 3our #yes. 6. Writing a. /a$e patient !rite a complete sentence of their choosing. f they are unsure !hat to !rite" suggest something about the !eather" or ho! much they like their doctor. #. M#mo$-. 1. Begistration9 Bepeat these !ords after me9 apple" table" penny. *o not proceed to memory testing until patient says them all correctly. 2. mmediate Becall9 1; minutes later" What !ere those ; !ords asked you to remember7 ;. Becent memory9 What did you ha$e for breakfast this morning7 e sure to ask something that you can confirm. . Bemote memory9 Where did you gro! up)go to school7 When !as your !edding)child born)military ser$ice7 'sk a family member to confirm. 4. Hi2h#$ i,t#""#'t.a" ).,'tio,. 1. (eneral kno!ledge9 Name the last 5 presidents. 2. 'bstraction9 What does APeople in glass houses shouldn+t thro! stones+ mean7 ;. ,udgment9 What !ould you do if you found a sealed" stamped" addressed en$elope lying on the ground7 . nsight9 Why did your daughter bring you to the hospital7
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5. Beasoning9 /o! do a lie and a mistake differ7 Note+ the examples o! commands and Guestions used in assessing mental status that are pro"ided in the preceding section are merely examples, not speci!ic instructions you are expected to !ollow.
Cranal Ner/e(. (. CN I O")a'to$-. 1. /a$e patient close eyes. 2. cclude one nostril and test other using nonirritating substances Fe.g." $anilla" clo$es" coffeeG. '$oid those that stimulate trigeminal ner$e endings or taste buds Fe.g." peppermint" menthol" ammoniaG. ;. Compare 2 sides. /. CN II Oti'. 1. Visual acuity. a. e sure your -nellen chart is a manufactured card. %hose that are copied or printed in handbooks ha$e poor contrast sensiti$ity or are not standardi=ed. 'l!ays test acuity and $isual fields before shining a bright light in patient+s eyes. e sure to ha$e good lighting in the room. b. /old -nellen chart at distance specified on the card. Fusually 1 inchesG. c. Co$er 1 eye and ha$e patient read chart. d. 4or each eye" record smallest line patient can read. Push patient to continue reading smaller lines until mistakes occur. -ome patients make careless mistakes if they read too fast^ask them to try the ne&t line or read more slo!ly if you think they can do better. e. (lasses should be left on Flooking for optic ner$e lesion" not refracti$e errorG. f. f $ision is !orse than 2<)25" do the pinhole test to determine !hether poor $ision is due to a refracti$e error or to a $isual path!ay lesion. Bepeat steps b through d !hile patient is looking through a 1 mm pinhole in a sheet of cardboard or a plastic card Fe.g." old * or credit cardG. Dooking through a pinhole allo!s only central rays of light to enter the eye" !hich impro$es $ision !ith a refracti$e error but not !ith a $isual path!ay lesion. 2. Visual fields. a. -tand directly in front of patient and ha$e patient look at your nose. b. /old your hands \1 ft. a!ay from patient+s ears and !iggle a finger on one hand. c. 'sk patient to indicate on !hich side the finger is mo$ing. d. Bepeat in upper and lo!er temporal 8uadrants. e. f abnormality is suspected or is found on screening test abo$e" test all 8uadrants of each eye indi$idually. i. /a$e patient close one eyeS you should close your o!n eye that is opposite the patient+s closed eye" since you !ill be ser$ing as the normal control. ii. @o$e a finger or penlight into the periphery of each $isual 8uadrant Fupper and lo!er temporal and nasalG" asking patient to indicate !hen mo$ement is detected. t should be seen by you and patient at the same time. ;. 4undoscopy. a. /a$e patient focus on distant !all. b. e sure your head is not obstructing patient+s $ie! of that target. c. Vie! optic disc using ophthalmoscope. d. Note disc color and presence of $enous pulsations" papilledema Fdisc hyperemia" blurred margins" absent $enous pulsationG" or hemorrhages. . Pupillary function FCN and CN G. a. %est pupillary reaction to light. i. %he room should be as dark as possible. ii. 'sk patient to look into distance to a$oid effect of accommodation. iii. -hine bright light obli8uely into each pupil. i$. Dook for both direct Fsame eyeG and consensual Fother eyeG constriction. Note !hether pupillary reacti$ity is prompt" sluggish" or absent. $. Becord pupil si=e in mm Fnormal is about 25 mmG and any asymmetry or irregularity. b. f pupillary reaction to light is abnormal" test pupillary reaction to accommodation. i. /old finger 1< cm from patient+s nose. ii. /a$e patient alternate looking into distance and at finger. »
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iii. bser$e pupillary response. .
CN III IV VI O'."omoto$ T$o'h"#a$ Ab/.'#,s. 1. Visual inspection. a. Dook at ocular alignment at rest Fprimary ga=eG. *oes light refle& hit at same location in each eye7 s one eye de$iated in" do!n and out" or up7 're there any ?erking mo$ements in primary position Flooking straight aheadG7 b. bser$e for ptosis Flid droopinessG. 2. 6 cardinal directions of ga=e. a. -tand ;6 feet in front of patient. b. 'sk patient to follo! your finger !ith the eyes !ithout mo$ing the head. Place your hand on top of head to keep it still if necessary. c. @o$e your finger slo!ly in the si& cardinal directions Fsee figureG and obser$e !hether mo$ements are full in each eye. Note !hether the eyes follo! your finger smoothly Fsmooth pursuitsG and !hether there is any hori=ontal" $ertical" or rotary nystagmus Fin$oluntary oscillation of the eyeballG. /a$e patient hold eyes at endga=e for a fe! seconds to be sure there is no nystagmus or slippage.
;. Con$ergence. a. 'sk patient to follo! your finger !ith the eyes !ithout mo$ing the head. /old lids up if necessary. b. @o$e your finger For the patient+s thumbG to!ard bridge of patient:s nose and obser$e eye mo$ements. . -mooth pursuits Fsmooth follo!ing mo$ementsG. a. %his !as tested !ith eye mo$ements F2" abo$eG. 5. -accades Fdiscrete" rapid mo$ements from one ob?ect to anotherG. a. Place your inde& finger at a position ?ust short of lateral endga=e. Position your nose slightly lateral to midposition in the opposite direction. 'sk patient to look alternati$ely at your finger and then your nose.. b. bser$e accuracy !ith !hich eyes reach target. *o they consistently o$ershoot or undershoot7 *o eyes mo$e con?ugately7 c. Bepeat on other side. 6. Nystagmus. a. bser$e for nystagmus on primary ga=e and !ith smooth pursuits F1 and 2" abo$eG. b. f present" note direction of mo$ement and !hether mo$ement persists or fatigues Fo$er !hat time periodG. c. Fa fe! beats of nystagmus at e&tremes of ga=e is a normal findingG E. Pupillary light response. Fsee CN G ,.
CN V T$i2#mi,a". 1. 4acial sensation. a. #&plain to patient !hat you intend to do. b. >se sharp end of a broken cotton s!ab or a pin to test pain sensation on forehead" cheek" and ?a! of each side of face. c. 'sk patient to tell you !hether it feels about the same on both sides. d. f not" map out !here abnormality is to see if it conforms to distribution of trigeminal ner$e. -pecifically" march stimulus from forehead back past hairline" from cheek to tragus of the ear" and from ?a! to neck. FV1 e&tends far back to the top of the skull^it does not end at the hairline. V; ends ?ust abo$e the ?a! line inferiorly and ?ust before the ear laterally.G
e. 4or mapping areas of diminished sensation" start in the numb area and ask patient to indicate !hen sensation becomes normal. 2. Corneal refle& FCN V and CN VG. a. Dightly touch peripheral aspect of cornea !ith fine !isp of cotton. V6.15.11
5;
b. Dook for normal blink reaction of both eyes. c. Bepeat on other side. d. f response is less than brisk" touch cornea more centrally Fo$er the irisG. ;. %emporalis and masseter strength. a. 'sk patient to open mouth and clench teeth. b. Palpate temporalis and masseter muscles. H. CN VII Fa'ia". 1. bser$e for any facial asymmetry at rest in forehead !rinkles" palpebral fissure !idth" nasolabial folds" or corner of mouth. 2. 'sk patient to do the follo!ing and note any lag" !eakness" or asymmetry9 a. -mile. b. Puff out cheeks. c. Close both lips and resist your attempt to open them. d. Close both eyes and resist your attempt to open them. e. Baise eyebro!s. ;. Corneal refle& Fsee CN VG. D. CN VIII A'o.sti' . 1. -creen hearing a. 4ace patient and hold out your arms !ith your fingers near each ear. b. Bub your fingers together on one side. c. 'sk patient to tell you !hen and on !hich side the rubbing is. d. ncrease intensity as needed. e. Note any asymmetry. @. CN IB & B G"ossoha$-,2#a" & Va2.s . 1. Disten to patient+s $oice. Note any hoarseness" nasal" or breathy 8uality. 2. 'sk patient to say 'h and !atch mo$ement of soft palate and pharyn&. F*o not pay attention to u$ula" !hich can de$iate to one side or another in the normal person.G a. Note any asymmetry of palate ele$ation. ;. 'sk patient to s!allo! and to cough. . n the unconscious or uncooperati$e patient" test gag refle&. a. -timulate back of throat !ith a cotton s!ab on each side. b. Dook for gagging after each stimulus. N. CN BI Si,a" A''#sso$-. 1. %rape=ius. a. 4rom behind patient" look for atrophy or asymmetry of trape=ii. b. 'sk patient to shrug shoulders against resistance and note strength. c. 'sk patient to push head back against resistance and note strength. 2. -ternocleidomastoid. a. Place hand on lo!er face and ask patient to turn head to!ards that side against resistance. b. bser$e contraction of opposite sternocleidomastoid. . CN BII H-o2"ossa". 1. Note tongue position at rest in the mouth and on protrusion. *oes tongue de$iate in either position7 2. 'sk patient to stick out tongue and mo$e it 8uickly from side to side. Note strength and rapidity of mo$ements. ;. /a$e patient push tongue into each cheek !hile you push from the outside. Note strength.
Mtr S$(te". P. Vis.a" i,s#'tio,. 1. Note muscle bulk. Dook for generali=ed or focal muscle !asting or hypertrophy. 2. Dook for e&traneous mo$ements" e.g." tremor F't rest7 With action7G" fasciculation Fmuscle t!itchingG. ;. Note speed of mo$ement" e.g." slo! to initiate FbradykinesiaG T. To,# Fmuscle tension at restG. V6.15.11
5
1. 'sk patient to rela&. 2. 4le& and e&tend patient+s !rists" elbo!s" shoulders" ankles" and knees. ;. Dook for resistance that is decreased FhypotoniaG or increased Fthroughout range of motionRrigidityS spring likeRspasticityG. B. St$#,2th a,/ E,/.$a,'#. 1. solate muscle you are testing so patient can+t use strong muscles that ha$e similar function to compensate for !eak one being tested. 2. 4i& pro&imal ?oint !hen testing distally. #.g." if testing pronation" fi& the humerus" so patient can+t use shoulder to compensate for !eak pronation. ;. (i$e yourself the ad$antage. #.g." !hen testing deltoid" press on outstretched hand rather than on elbo!. 3ou need to test !ith ade8uate po!er to detect a subtle abnormality" especially if the patient is larger than you. . /a$e patient !alk on heels and toes and do deep knee bend or get out of chair !ithout using arms. 5. %est at least the follo!ing muscles on both sides9 a. *eltoid9 abduction Fele$ationG of upper arm FC56S a&illary ner$eG b. iceps9 fle&ion of forearm at elbo! FC56S musculocutaneous ner$eG c. %riceps9 e&tension of forearm at elbo! FC6JS radial ner$eG d. #&tensor carpi radialis9 dorsifle&ion of hand at !rist FC56S radial ner$eG e. 'bductor pollicis bre$is9 palmar abduction of thumb !ith thumb at right angle to palm FCJ%1S median ner$eG f. nterossei9 finger abduction FdorsalG and adduction FpalmarG FCJ%1S ulnar ner$eG g. liopsoas9 hip fle&ion FD1;S femoral ner$eG h. Tuadriceps9 knee e&tension FD2S femoral ner$eG i. /amstrings9 knee fle&ion FD5-2S sciatic ner$eG ?. %ibialis anterior9 foot dorsifle&ion FD5S deep peroneal ner$eG k. (astrocnemius)soleus9 foot plantar fle&ion F-12S tibial ner$eG 6. 'ssign score of <5 for each muscle based on @edical Besearch Council scale. Pluses and minuses are sometimes used to note asymmetries or to further refine the scale. G$a/# D#s'$itio,
<)5
No muscular contraction
1)5
Visible muscle contraction" but no mo$ement at the ?oint
2)5
@o$ement at the ?oint" but not against gra$ity
;)5
@o$ement against gra$ity" but not against added resistance
)5
@o$ement against resistance" but less than full
5)5
@o$ement against full resistanceS normal strength
E. Note if strength fatigues after sustained muscle contraction. R#)"#=#s! -. M.s'"# st$#t'h $#)"#=#s. 1. Position patient so that you can access the refle& on both sides !ith the same angle and hammer speed. /a$e patient rela& the limb. 2. %ap the tendon)periosteum to !hich muscle is attached. ;. bser$e $igor and briskness of response and compare sidetoside. 'symmetry is $ery important to note and may be subtle. . f refle&es are diminished or absent" try reinforcing the refle& by distraction or $ia isometric contraction of other muscles Fclenched teethG. 5. f refle&es are $ery brisk" try to bring out subtle asymmetries by using the lightest tap that !ill elicit the refle&. 6. %est at least the follo!ing refle&es9 Fspinal ner$e root in bold is the predominant contributorG a. iceps FC5" C0S musculocutaneous ner$eG i. Patient:s arm should be partially fle&ed at the elbo! !ith palm do!n. ii. Place your thumb or finger firmly on biceps tendon. V6.15.11
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iii. -trike your finger !ith refle& hammer. i$. 3ou should feel the response e$en if you can:t see it. b. %riceps FC6" CS radial ner$eG i. f patient is seated9 support upper arm and let forearm hang free. ii. f patient is lying do!n" fle& arm at elbo! and hold it close to chest. iii. -trike the triceps tendon abo$e the elbo!. c. Hnee FD2" D;" L8S femoral ner$eG i. /a$e patient sit or lie do!n !ith knee fle&ed. ii. -trike patellar tendon ?ust belo! patella. iii. Note contraction of the 8uadriceps and e&tension of the knee. d. 'nkle FS7" -2S tibial ner$eG i. *orsifle& foot at ankle to keep muscle in slight tension. ii. -trike 'chilles tendon. 'lternati$ely" you can strike the ball of the foot if the patient is lying in bed. iii. Watch and feel for plantar fle&ion at the ankle. E. %est for clonus Frhythmic oscillations of fle&ion)e&tensionG at the ankle i. -upport knee in a partly fle&ed position. ii. With patient rela&ed" 8uickly dorsifle& foot. iii. bser$e for rhythmic oscillations. J. 'ssign grade on scale of <. G$a/# D#s'$itio,
<
'bsent
1
/ypoacti$e Fincreased thresholdS decreased speed" $igor" I range of responseG
2
Normal
;
risk)hyperacti$e Fdecreased thresholdS increased speed" $igor" I range of responseG
@arkedly hyperacti$e !ith clonus and)or spreading to other muscles
%. P"a,ta$ $#so,s# FD-2" especially -1S tibial ner$eG. 1. >sing the end of a refle& hammer" the tines of the tuning fork" a broken tongue blade" or a key" stroke lateral aspect of the sole of each foot from heel to toes" then drag the stimulus across the foot ?ust beneath the toes. 2. Note mo$ement of toes. ;. f no response" increase pressure of stroking. . f patient ticklish or !ithdra!ing !hole foot" either ha$e patient stroke o!n foot or apply stimulus along lateral aspect of foot only. 5. 4le&ion of all toes Fdo!ngoing toeG is a normal response. #&tension of the great toe Fupgoing toeS positi$e abinskiG !ith fanning of the other toes is abnormal.
. S#,so$- S-st#m. '. (eneral points. 1. #&plain each test before you do it. f the patient is a!are of any numb areas" you can ask them to indicate these before you start. /o!e$er" don+t assume or be biased in your more detailed testing. 2. >nless other!ise specified" the patient:s eyes should be closed during testing. ;. %est all e&tremities. . Compare side to side and ask if the t!o sides are about the same. '$oid leading 8uestions like s this sharp7 5. Compare distal and pro&imal areas of the e&tremities. 6. When you detect an area of sensory loss" map out its boundaries in detail. -tart in the area of diminished sensation" and mo$e to the area of more normal sensation. . Vib$atio, . V6.15.11
56
C.
*.
#.
4.
(.
/.
.
1. >se a 12J/= Flo!pitchedG tuning fork a. Dightly strike tines against your hand and place stem of the fork o$er most distal ?oint of patient+s great toe. b. 'sk !hether patient feels anything and !hat the sensation is. c. f $ibration is felt" ask !hen it goes a!ay. Count number of seconds. d. Bepeat on other side" being sure to strike the fork !ith about e8ual force" and compare duration $ibration is felt. e. f $ibration sense is impaired" mo$e pro&imally one ?oint at a time until it is felt. f. %est the fingers in a similar fashion. oi,t ositio, s#,s#. 1. (rasp patient:s great toe on sides of distal phalan& and hold it a!ay from other toes to a$oid friction. 2. *emonstrate to patient !hat up and do!n feel like and tell patient you !ill mo$e the toe in one of these t!o directions only. ;. @o$e toe a fe! degrees and ask patient to identify direction in !hich toe !as mo$ed. . f position sense is impaired" increase stimulus intensity Fmo$e toe a greater distanceGS if still impaired" test at more pro&imal ?oint Fankle kneehipG. 5. %est fingers in a similar fashion. Pai,. 1. >se a safety pin or sharp end of a broken cotton s!ab. 2. %est for a distal gradient of sensory loss in leg by applying stimulus at toes and marching your !ay up to knee. a. 'sk patient if the sensation is about the same or if it changes as you mo$e up the leg. ;. %est for sensory loss in most commonly affected ner$e and ner$e root distributions. a. %est the follo!ing areas9 i. Palmar aspect of inde& finger Fmedian ner$eG. ii. Palmar aspect of 5th finger Fulnar ner$eG. iii. Web space bet!een thumb and inde& finger on dorsal surface of hand Fradial ner$eG. i$. Dateral surface of foot FD5G. $. Posterior aspect of leg F-1G. b. 'pply stimulus to one and then another of these locations in the upper or lo!er e&tremity" asking patient if the t!o areas are about the same. . n the patient complaining of sensory symptoms" mo$e stimulus from abnormal area to normal area" asking patient to report !hen stimulus begins to feel stronger. a. 'nother techni8ue is to apply stimulus to an unin$ol$ed part of the body and say" f this sharpness)coolness is !orth `1" ho! much is this !orth7 and then apply stimulus to the in$ol$ed part. 5. f there is any suspicion of a spinal cord lesion Fe.g." bladder complaints" brisk lo!er e&tremity refle&esG or if there is patchy sensory loss in the legs" test for a spinal le$el. %his is done by marching up each side of the back !ith a pin" looking for a consistent le$el belo! !hich sensation is impaired. T#m#$at.$#. 1. %esting of temperature is usually reser$ed for the patient in !hom testing of pain sensation is abnormal. 2. Press a cold tuning fork against the skin to make sure there is temperature loss in same distribution as pain loss. Li2ht to.'h. 1. %ouch the skin lightly !ith a piece of cotton. 2. 'sk patient to respond !hene$er a touch is felt Fe.g." left armG. ;. %est face" arms" and legs in random order. Do.b"# sim."ta,#o.s stim."atio, Ftest for e&tinction)tactile neglectG. 1. Can be performed only !hen light touch is intact. 2. %ouch both sides of patient+s face or body simultaneously. ;. 'sk patient to indicate !hether touch is felt on the left" right" or both. G$ah#sth#sia Fintegrati$e sensationG. 1. Can be performed only !hen light touch is intact. 2. >sing a pen cap" paper clip" or your finger" dra! a number in patient+s palm or" for more sensiti$ity" on the inde& finger. e sure to dra! the number so it is facing the patient. ;. 'sk patient to identify the number. St#$#o2,osis Fintegrati$e sensationG. 1. Can be performed only !hen light touch and position sense are intact.
V6.15.11
5E
,.
2. Place a familiar ob?ect Fe.g." coin" paper clip" keyG in patient+s hand. ;. 'sk patient to mo$e it around using fingers and to identify it. Romb#$2. 1. /a$e patient stand !ith feet together and eyes open. Watch for s!aying and compensating mo$ements of the feet and toes. 2. /a$e patient close eyes. ;. /old your arms out to steady)catch patient if necessary. . Watch for de$elopment of s!aying or falling !hen eyes are closed Fpositi$e BombergG^indicates either impaired proprioception or $estibular dysfunction. 5. t is normal for the feet and toes to mo$e and shift !eight. %his indicates that propriocepti$e sense is intact. Patients !ho ha$e lost propriocepti$e sense !ill not compensate" and !ill start to fall" only kno!ing that they are falling because their $estibular sense has been triggered.
Coo$/i,atio,. H. T$.,'a" stabi"it-. 1. bser$e patient sitting on a chair or side of bed !ith hands in lap. F@ake sure if patient sitting on side of bed that bed is reclined flat.G 2. Note any leaning to!ards one side or falling back!ards. D. Fi,# )i,2#$ mo+#m#,ts 5)i,2#$ tai,26. 1. /a$e patient tap thumb to tip of inde& finger as big and fast as possible. 2. bser$e rhythm" speed" and precision of mo$ements. ;. Bepeat on other side. @. To# tai,2. 1. /a$e patient tap your hand !ith ball of each foot as fast as possible. 2. bser$e rhythm" speed" and precision of mo$ements. ;. Bepeat on other side. N. Fi,2#$1,os#1)i,2#$. 1. /a$e patient alternately touch your outstretched finger and o!n nose. 2. e sure your finger is far enough a!ay that patient+s arm must fully e&tend to reach it. f the elbo! is bent" you may miss subtle deficits. ;. bser$e speed" and precision of mo$ements. Note any tremor" especially one that !orsens as patient+s finger nears the target. Note if patient consistently passes Fo$ershootsG" fails to reach FundershootsG" or is off to left or right of target. . Bepeat on other side. . H##"1%,##1shi,. 1. Patient can be lying or sitting. Place heel of one foot ?ust belo! knee of the other leg. 2. /a$e patient run that heel up and do!n shin of other leg. ;. bser$e speed" and precision of mo$ements. Note any tremor. . Bepeat on other side. P! Rai/ A"t#$,ati,2 Mo+#m#,ts 1. /a$e patient alternately tap dorsal and plantar surface of one hand onto other hand" the thigh" or the bed Fas fast as possibleG. 2. bser$e rhythm" speed" and precision of mo$ements. Statio, a,/ Gait T. bser$e the patient do the follo!ing9 1. Bise from a seated position. 2. Walk across room" turn" and come back. ;. Walk on toes. . Walk on heels. 5. Walk heel to toe Ftandem gaitG in a straight line. F@any other!ise normal elderly people cannot perform this task.G 6. /op on each foot. B. e prepared to catch the patient if necessary. f there is any doubt in your mind as to !hether the patient may fall" get assistance Fnurse" patient care technician" residentG before testing gait. *o not use this doubt as a reason not to test gait" ho!e$er. -. Pay attention to the follo!ing9
V6.15.11
5J
1. Posture of body and e&tremities Fe.g." leaning or pulling to!ards one side or back!ards" t!isting or holding back one armG. 2. Dength" speed" and rhythm of steps. ;. ase of gait Fho! far apart are the legsG. . 'rm s!ing Fis it reduced unilaterally or bilaterallyG. 5. -teadiness. 6. %urning Fsteadiness of turns and number of steps re8uired to complete the turnG. M#,i,2#a" Si2,s. %. 'sk patient to fle& and e&tend neck. >. Passi$ely fle& and e&tend patient+s neck. V. bser$e for palpable stiffness on either acti$e or passi$e mo$ement.
V6.15.11
5K
Sam"# ,#.$o"o2i'a" H & P CC %he patient is a 5<yearold righthanded !oman !ith a history of chronic headaches !ho complains of acute onset of double $ision and right eyelid droopiness three days ago. Histo$- o) $#s#,t i"",#ss9 @rs. -mith states that on -unday e$ening FE)1)<;G about 2< minutes after sitting do!n to !ork at her computer" she de$eloped blurred $ision" !hich she describes as the !ords on the computer looking fu==y and seeming to run into each other. When she looked up at the clock on the !all" she had a hard time making out the numbers. 't the same time" she also noted a strange sensation in her right eyelid. -he !ent to bed and upon a!akening the follo!ing morning" she !as unable to open her right eye. When she lifted the right eyelid !ith her fingers" she had double $ision !ith the ob?ects appearing side by side. %he double $ision !as most prominent !hen she looked to the left" but !as also present !hen she looked straight ahead" up" do!n" and to the right" and !ent a!ay !hen she closed either of her eyes. -he also noted that she had pain in both of her eyes that increased if she mo$ed her eyes around" especially on looking to the left. -he !as seen in the 'lton @emorial /ospital #B and subse8uently transferred to ,/ by ambulance.
@rs. -mith also notes that for the past t!o to three !eeks" she has been ha$ing intermittent pounding bifrontal headaches that !orsen !ith straining" such as !hen coughing or ha$ing a bo!el mo$ement. %he headaches are not positional and are not !orse at any particular time of day. -he rates the pain as E or J on a scale of 1 to 1<" !ith 1< being the !orst possible headache. %he pain lessened some!hat !hen she took Vicodin that she had lying around. -he denies associated nausea" $omiting" photophobia" loss of $ision" seeing flashing lights or =ig=ag lines" numbness" !eakness" language difficulties" and gait abnormalities. /er recent headaches differ from her typical migraines" !hich ha$e occurred about 6 times per year since she !as a teenager and consist of seeing shimmering !hite stars mo$e hori=ontally across her $ision for a couple minutes follo!ed by a pounding headache behind one or the other eye" photophobia" phonophobia" and nausea and $omiting lasting se$eral hours to t!o days. -he has ne$er taken anything for these headaches other than ibuprofen or Vicodin" both of !hich are partially effecti$e. %he last headache of that type !as t!o months ago. /er $isual symptoms ha$e not changed since the initial presentation. -he denies pre$ious episodes of transient or permanent $isual or neurologic changes. -he denies head trauma" recent illness" fe$er" tinnitus or other neurologic symptoms. -he is not a!are of a change in her appearance" but her husband notes that her right eye seems to protrudeS he thinks that this is a change in the last fe! days. Past m#/i'a" histo$-9 1G @igraine headaches" as described in /P. 2G *epression. %here is no history of diabetes or hypertension. M#/i'atio,s9 Uoloft 5< mg daily" ibuprofen 6<< mg a fe! times per !eek" and Vicodin a fe! times per !eek. A""#$2i#s9 None. So'ia" histo$-9 %he patient li$es !ith her husband and 16yearold daughter in a 2story singlefamily house and has !orked as a medical receptionist for 25 years. -he denies tobacco or illicit drug use and rarely drinks a glass of !ine. Fami"- histo$-9 /er mother had migraines and died at the age of E< after a heart attack. /er maternal grandfather had a stroke at age 6K. %here is no other family history of stroke or $ascular disease" but she has no information about her father+s side of the family. R#+i#3 o) s-st#ms9 -he states that she had an upper respiratory infection !ith rhinorrhea" congestion" sore throat" and cough about 6 !eeks ago. -he denies fe$er" chills" malaise" !eight loss" neck stiffness" chest pain" dyspnea" abdominal pain" diarrhea" constipation" urinary symptoms" ?oint pain" or back pain. Neurologic complaints as per /P. G#,#$a" h-si'a" #=ami,atio,9 %he patient is obese but !ellappearing. %emperature is ;E.6" blood pressure is 12J)EJ" and pulse is J5. %here is no tenderness o$er the scalp or neck and no bruits o$er the eyes or at the neck. %here is no proptosis" lid s!elling" con?uncti$al in?ection" or chemosis. Cardiac e&am sho!s a regular rate and no murmur. N#.$o"o2i' #=ami,atio,9 @ental status9
V6.15.11
6<
%he patient is alert" attenti$e" and oriented. -peech is clear and fluent !ith good repetition" comprehension" and naming. -he recalls ;); ob?ects at 5 minutes. Cranial ner$es9 CN 9 Visual fields are full to confrontation. 4undoscopic e&am is normal !ith sharp discs and no $ascular changes. Venous pulsations are present bilaterally. Pupils are mm and briskly reacti$e to light. Visual acuity is 2<)2< bilaterally. CN " V" V9 't primary ga=e" there is no eye de$iation. When the patient is looking to the left" the right eye does not adduct. When the patient is looking up" the right eye does not mo$e up as !ell as the left. -he de$elops hori=ontal diplopia in all directions of ga=e especially !hen looking to the left. %here is ptosis of the right eye. Con$ergence is impaired. CN V9 4acial sensation is intact to pinprick in all ; di$isions bilaterally. Corneal responses are intact. CN V9 4ace is symmetric !ith normal eye closure and smile. CN V9 /earing is normal to rubbing fingers CN " 9 Palate ele$ates symmetrically. Phonation is normal. CN 9 /ead turning and shoulder shrug are intact CN 9 %ongue is midline !ith normal mo$ements and no atrophy. @otor9 %here is no pronator drift of outstretched arms. @uscle bulk and tone are normal. -trength is full bilaterally. *eltoid iceps %riceps Wrist e&tension D 5 5 5 5 B 5 5 5 5
4inger abduction 5 5
/ip fle&ion 5 5
/ip e&tension 5 5
Hnee fle&ion 5 5
Hnee e&tension 5 5
'nkle fle&ion 5 5
'nkle e&tension 5 5
Befle&es9 Befle&es are 2Q and symmetric at the biceps" triceps" knees" and ankles. Plantar responses are fle&or. -ensory9 Dight touch" pinprick" position sense" and $ibration sense are intact in fingers and toes. Coordination9 Bapid alternating mo$ements and fine finger mo$ements are intact. %here is no dysmetria on fingertonose and heel kneeshin. %here are no abnormal or e&traneous mo$ements. Bomberg is absent. (ait)-tance9 Posture is normal. (ait is steady !ith normal steps" base" arm s!ing" and turning. /eel and toe !alking are normal. %andem gait is normal !hen the patient closes one of her eyes. Labo$ato$- Data FBecord here all a$ailable lab dataS circle any abnormal $aluesG. C% FnoncontrastG E)1E9 no abnormalities. rbits not !ell seen.
@B E)1J9 @ultifocal areas of increased signal on %2 and 4D'B in the deep !hite matter bilaterally. %hese range in si=e from 1 to 1< mm and do not enhance after administration of gadolinium. %here are no signal abnormalities in the brain stem or in the corpus callosum. No abnormalities in orbits" sinuses" or $enous structures. Ass#ssm#,t n summary" the patient is a 5<yearold !oman !ith longstanding headaches !ho has had an acute onset of pupilsparing partial third ner$e palsy on the right Fin$ol$ing le$ator palpabrae" superior rectus" and medial rectusG associated !ith a bifrontal headache. ecause this is an isolated third ner$e palsy !ithout in$ol$ement of other cranial ner$es or orbital abnormalities" the lesion is locali=ed to the ner$e itself" e.g. in the subarachnoid space. phthalmoplegic migraine remains a likely diagnosis gi$en the history of migraine !ith aura" e$en though the current headache is different in character from her usual headaches and is not associated !ith $isual aura" nausea)$omiting" or photophobia. /o!e$er" other potentially serious causes of third ner$e palsy must be e&cluded. f a third ner$e palsy is due to a compressi$e lesion" the pupillary fibers !ill generally become in$ol$ed !ithin about one !eek of the onset of symptoms. -o the fact that her pupil is normal in si=e and reacti$e to light !eighs against the diagnosis of a compressi$e lesion such as an aneurysm or tumor" but does not eliminate the possibility. V6.15.11
61
%he @B does not sho! e$idence of a mass lesion" but an aneurysm cannot be completely e&cluded !ithout an angiogram. 'nother potentially serious cause of the third ner$e palsy is meningitis. %he patient is afebrile" has no meningeal signs" is !ellappearing" and has been stable o$er three days" making bacterial meningitis highly unlikely" but atypical meningitis including fungal" Dyme" sarcoid or carcinomatous meningitis are possibilities. 4inally" the patient may ha$e a $ascular lesion of the third ner$e due to unrecogni=ed diabetes. %he appearance of the @B abnormalities is nonspecific. %he lesions are potentially e&plainable by migraines" but are also consistent !ith hypertension or a $asculopathy. %he patient denies a history of hypertension" is not currently hypertensi$e" and has no risk factors for $ascular disease" but the possibility of a genetic disorder such as C'*'-D cannot be e&cluded gi$en the lack of paternal history. P"a, Problem 1. B rd ner$e palsy.
%he patient !ill undergo a cerebral angiogram to e$aluate for an aneurysm" particularly a posterior communicating aneurysm. Patient has been informed of risks and benefits of this procedure and it is scheduled for '@. -he !ill be kept NP for the procedure. ' lumbar puncture !ill be performed !ith opening pressure assessed and C-4 sent for cell count and differential" protein" glucose" cultures and cytology. -he !ill ha$e her glucose and hemoglobin '1C dra!n to e$aluate for diabetes. -he !ill ha$e close obser$ation for possible neurologic !orsening including neuro checks e$ery hours for first 2 hours. -he !ill be gi$en an eye patch for comfort to eliminate the diplopia. Problem 2. /eadache. -he !ill be gi$en a trial of naprosyn << mg po bidS if this is ineffecti$e" she may re8uire narcotic analgesia !hile her e$aluation is being completed. f the cerebral angiogram and lumbar puncture are negati$e and her headache does not impro$e" she may be a candidate for V dihydroergotamine treatment. *espite the infre8uency of her migraines" the occurrence of a debilitating migraine !ith neurological deficits !arrants the use of a prophylactic agent. ' tricyclic antidepressant !ould be a good choice gi$en her history of depression. Problem ;. *epression. %he patient denies current symptoms and !ill continue Uoloft at current dose. Problem . besity. %he patient re8uests referral to a dietician.
V6.15.11
62
P#$)o$mi,2 a L.mba$ P.,'t.$# o, N#.$o"o2-
1. 2. ;. . 5. 6.
E. J. K. 1<.
11. 12.
1;. 1. 15. 16. 1E. 1J. 1K. 2<. 21. 22. 2;. 2. 25. 26. 2E. 2J. 2K. ;<. ;1.
Check coags)plts" NB Z 1.5" plts [ 5<" don+t forget about the P%%. @ake sure there is no risk of herniation Flook for papilledema and check the /C%G. btain consent" place it in the chart" and e&plain the procedure to the patient. (i$e V 'ti$an to an&ious patients. btain a DP kit. (ather !hat is not in the DP kit9 a. sterile glo$es Fbring an e&tra pairG b. nonsterile glo$es c. pen d. e&tra lidocaine Fonly 2mD is in the kitS !rite an order for either a 1L or 2L 5mD bottle" and ask the nurse to get it out of py&isG e. sprotte needle f. betadine g. plenty of e&tra & gau=e. h. chuck pad i. sterile to!els FoptionalG ?. yello! face mask Place the yello! sticker from the DP kit on the card inside the red binder at the nurses station. Place all e8uipment on a food tray table" !ith a trash can at arms length. 'd?ust the height of the bed to your comfort le$el. Positioning is key. f opening pressure is needed" the patient needs to be in the lateral decubitus position. ther!ise DPs can be done sitting up much more easily" particularly for the obese. f sitting up" ha$e the patient rest his)her legs on the side of the bed" then ha$e them lean o$er the food tray table. Wash your hands. Put on your nonsterile glo$es. @ark !ith your pen the e&act location !here you !ill insert the spinal needle. %he superior iliac crest lines up !ith the D spinous process. With the pad of your thumb you should be able to simultaneously feel both the spinous process and the interspace. (et a feel for the interspace along both the $ertical and hori=ontal plane. 'l!ays make your first attempt at DD5 before mo$ing up to D;D. %uck the chuck pad under the patients back and buttocks so the betadine !ill not get on the bed. pen the DP kit and the sterile glo$e packet. pen the betadine bottle and pour into the reser$oir inside the kit. @ake sure you s8uirt a!ay from yourself. etadine !ill stain and ruin your clothes. pen the top of the lidocaine bottle Fthe larger one that did not come !ith the kitG and place on the outer sterile !hite co$ering that surrounds the kit. @ake sure to not touch the top of the bottle !ith your nonsterile hands. pen up the e&tra gau=e packets and drop them into the sterile field. Put on your face mask. Put on the sterile glo$es. >nscre! the caps of all of the C-4 collection tubes and place them in order that they are to be collected. -et up the manometer and turn the stopcock 1Jsing all of the pink sponges in the kit" apply betadine in concentric circles. %ake a large piece of gau=e from your sterile field and use it to pick up the nonsterile lidocaine bottle *ra! lidocaine into the syringe. Clean off the betadine directly abo$e the chuck and the patient+s back !ith a sterile piece of gau=e. %here are t!o sterile drapes in the DP kit. %ake the tape off the blue drape Fthe one !ith a s8uare in the middleG" and stick it directly on the patient+s back !here you ha$e ?ust remo$ed the betadine. -lightly fold the blue drape so the middle s8uare is not e&posed. %his drape !ill lie o$er the chuck and !ill ser$e as a sterile area !here you can rest your hands. Place the !hite sterile drape o$er the iliac crest" this !ill allo! you to find your interspace !hile still remaining sterile. n the interim the patient has likely mo$ed and the markings you ha$e pre$iously made !ith your pen !ill no longer be accurate. 4ind your spot once again. 'pply lidocaine to the e&act spot o$erlying the desired interspace. Cut the skin !ith the needle included in the sprotte needle packet.
V6.15.11
6;
;2. Beconfirm the spot of the inter$ertebral space. >se your nondominate thumb as a guide" ha$ing the middle aspect of the pad of your thumb on the spinous process" and the tip of your thumb simultaneously pressing deeply into the interspace. ;;. %he needle should be inserted immediately ad?acent to the tip of your thumb" at 15 degrees cephalad" as if aiming at the patient+s umbilicus. ;. %he needle !ill pass through" in order" the skin" subcutaneous tissue" supraspinous ligament" interspinous ligament bet!een the spinous processes" ligamentum fla$um" epidural space Flocation of the internal $ertebral $enous ple&usG" dura" arachnoird" and into the subarachnoid space bet!een the ner$e roots of the cauda e8uina. ;5. 's the needle passes through the ligamentum fla$um" you may feel a popping sensation. ;6. f attempt is unsuccessful and bone is encountered" !ithdra! the needle to the subcutaneous tissue" !ithout e&iting the skin" and redirect the needle. @ake sure the stylet is hubbed against the needle !hene$er you pull out and redirect. ;E. nce you are in the space" !ithdra! the stylet in 2mm inter$als to assess C-4 flo!. f flo! is poor" you may rotate the needle K< o" since a ner$e may be obstructing the opening. ;J. f the tap is traumatic" the C-4 may be tinged !ith blood. %he blood should clear as additional C-4 is collected" unless the source of the blood is a subarachnoid hemorrhage. f you encounter frank blood and you are uncertain of being in the subarachnoid space" you ha$e probably hit a $ein in the internal $ertebral $enous ple&us. Pull out the needle and redirect. ;K. >se the fle&ible tube to connect the manometer Fstopcock already turned to!ard youG to the hub of the needle. ' measurement can be made after the column of fluid stops rising. <. 'fter measuring the opening pressure" turn the stopcock 1J< o to!ard the patient so the C-4 in the manometer can be collected in your first tube. 1. Bemo$e the manometer and collect ; cc of C-4 in each tube. \1< cc should be collected for either cytology or %rotter studies. 2. Put the stylet back into the DP needle and remo$e the needle. @ake sure the stylet has not been contaminated. ;. etadine left on the patient+s body is irritating to the skin. %horoughly clean the betadine off the patient+s back by using hand foam and paper to!els. . Write a procedure note in Compass. Print it" sign it" and place in chart. f someone super$ised" they need to !rite an addendum to that effect and also sign it. 5. Dabel all tubes. 'll labels must be initialed and dated)timed by you. 6. Write order for labels to be made" or make up re8uisitions yourself. Cytology re8uires a different form. E. Ha,/ /#"i+#$ all C-4 to the lab.
4ollo!ing are the labs !here each study goes. 3ou !ill need to send separate tubes to each lab" but you can get multiple labs on the same tube if they are going to the same place Fe&cept separate cell countsG. Call 21E< or 211
T.b#
Lo'atio, 1I /ematology 2 or ; Chemistry 2 or ; @icrobiology 2 or ; Chemistry 2 or ; @icrobiology 2 or ; Chemistry 1 or /ematology 2 or ; Chemistry 2 or ; Chemistry 'ny -urgical Pathology 2 or ; Chemistry" *on+t forget special form]]] N@ 'ntibody 2 or ; Chemistry 4lo! cytometry 'ny /ematology ] Cytology can only be done on !eekdays before ; pm. *N+% 4B(#% % B#T>#-% % -'V# ' %>#0
V6.15.11
6
NEUROLOGY STUDENT MID2ROTATION FEEDBACK FORM S+-/+) D+)
R23-/+)
%his form should be turned in to @ichelle by the ;rd @onday of the rotation. A P4567
B759 A:4;
A:4;
A65: A:4;
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1? A67 75@73 + 7235/
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? C5/2+4@+2 =4+3//+ /- =43543+3- -34/+37
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#? E<@77/+ 425/3/; 3/ 2222/+2
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(? C5/2+4@+2 75;3@7 /- +545; =7/
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&? A-32235/ /5+ 32 /+, +545;, =4+3//+, /- +37>
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$? SOAP /5+ 32 /+, +545;, =4+3//+, /- +37>
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%? O47 =42/++35/ 32 =4+3//+, 442-, /- -5/2+4+2 <@77/+ /597-; 5 + =+3/+ /- -322
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8? A67 +5 2>/+23 -+ /- = 63; =3@+4 3/ 3/-
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1? D-3@+- +5 -53/; +34 62+ 5/ +32 45++35/
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? I-/+332 9+ /-2 +5 6 -5/ 3/-=/-/+7>
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#? W3773/; +5 954!= =+3/+2
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(? A:3767 54 +@3/; /- -32@2235/
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&? F577592!+45; 5/ +22 /- 223;//+2
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$? E@+3:7> 22 -59/!+3 54 74/3/;
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1? K/597-; 5 -3222 /- =+5=>23575;>
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? K/597-; 5 -3;/52+3@2 /- +4=+3@2
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#? A22337+2 /- 22 /9 3/54+35/
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(? R@5;/32 /- @544@+2 /597-; -3@3/@32
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&? D5/2+4+2 27!-34@+- 74/3/;
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1? P/@+7 /- 2+>2 /+37 954 32 3/32-
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? D/54 ==45=43+ 54 7:7 5 +43/3/;
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Clnal S'll( 1? O6+3/2 @5=7+ 32+54> ? E3@3/+ /- 7<367, 2 + 23++35/ 4342 #? P4542 +545; <, 93+ 77 3/-3/;2 73@3+(? O6+3/2 32+54> 45 -33@7+ =+3/+2 /- =4+3//+ =5=7 &? R:392 4@54-2 /- /@3774> 3/54+35/ $? I/+4=425/7 23772 93+ =+3/+2 /- 3732
Anal/tal S'll(
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(? R2=@+7 5 =+3/+2, -32=7>2 @5=2235/, =+>, /-:5@@> &? R2=@+7 5 +, /-42+/-2 457 $? R2=5/-2 977 +5 @43+3@32
V6.15.11
65
1? W+ 4 +32 2+-/+2 +5= # 2+4/;+2
? W+ 4 # 3+2 ++ 434 3=45:/+ 5:4 + /<+ 92 W43+ -59/ 2=@33@77> 59 + 2+-/+ 9377 3=45: =5/ +2.
#? I2 + 2+-/+ 3/; =45;422 5/ + 2++- C7423= G572 /- O6@+3:2 4:39 +2? I /5+, 59 9377 +> 4-> +32
(? I2 + 2+-/+ +3/; + C7423= R34/+2 /- E<=@++35/2 I /5+, 59 9377 +> 4-> +32
&? A4 +4 /> --3+35/7 @5/+2 54 73342
$? I + 2+-/+ 32 2+4;;73/;, 4 +4 /> =425/7 54 2=@37 @34@2+/@2 +5 /5+ 3. 7+ =45672, 37> =45672, =425/7 3222, /+7 7+ =45672, 74/3/; -33@7+32, 5+4 @53+/+2, +@?
R23-/+ S3;/+4) C7423= D34@+54 S3;/+4)
S+-/+ S3;/+4) D+)
V6.15.11
66
NEUROLOGICAL E9AM FEEDBACK FORM -tudent9 *ate9 Besident9 3ou !ill be re8uired to hand in this form or a copy to the clerkship administrator by the 2nd %hursday of your rotation. /a$e resident fillout the form and re$ie! the comments. 4or students on Neurosurgery" you should ha$e this done by the Neurology teaching resident or chief resident. %his form is re8uired" and ser$es as instant feedback for you. f you are ha$ing trouble finding a time to do this !ith your resident" let the clerkship director kno! at your ne&t meeting. Needs mpro$ement
-atisfactory
#&emplary
1G ntroduced self to patient and others in the room
1
2
;
N)'
2G *emonstrates concern for patient comfort and modesty
1
2
;
N)'
;G Positions the patient properly
1
2
;
N)'
G >ses instruments correctly
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2
;
N)'
5G 4ollo!s a logical se8uence of e&amination
1
2
;
N)'
6G @odifies the e&am to adapt to the patients limitations
1
2
;
N)'
EG 4ocuses on most rele$ant parts of the e&am
1
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;
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aG @ental -tatus
1
2
;
N)'
bG Danguage
1
2
;
N)'
cG Cranial Ner$es
1
2
;
N)'
dG @otor
1
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N)'
eG Befle&es
1
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fG -ensory
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gG Coordination
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hG -tation and (ait
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JG #&amines each of the follo!ing correctly
OVERALL EVALUATION Fo$mati+# Comm#,ts
V6.15.11
6E
NEUROLOGY STUDENT SELF2ASSESSMENT FORM S+-/+) D+) R23-/+)
P72 4:39 93+ >54 423-/+ 54 3-!45++35/ -6@. S63+ @5=> 93+ -6@ 54.
S'll( O,-et/e(
ntegral team member on Neurology 'bility to get a detailed history under all circumstances Complete and accurate neurological e&am Coma e&am Presentations F5 minuteG Writeups -ynthesi=ing patient care data 'pplying kno!ledge Communicating !ith patients and families eginning to understand neuroimaging
Pr,le"2Ba(e& Kn7le&)e *isorders of consciousness @ental status and)or beha$ioral changes @emory complaints Pain in the head" neck" and back Numbness" paresthesias" and neuropathic pain Weakness and clumsiness *i==iness and $ertigo *isorders of language Neurogenic bladder and bo!el Vision loss and diplopia *ysarthria and dysphagia 'bnormal mo$ements -leeprelated complaints D(ea(e2Ba(e& Kn7le&)e schemic stroke rain /emorrhage -tructural coma @etabolic encephalopathies Neuroto&icology and $itamin deficiencies @eningitis and encephalitis *ementia and memory disorders -ei=ures and epilepsy Fincluding status epilepticusG -yncope
S5 -33@7+>
B;3//3/; +5 =45;422
S5 P45;422
G55P45;422
G4+ P45;422
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V6.15.11
6J
Vertigo /eadache Neck and back pain @yelopathies Badiculopathies Fincluding cauda e8uina syndromeG Ner$e compression Neuropathies @ultiple -clerosis Parkinson+s disease and tremor @yasthenia gra$is @yopathies rain tumors
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W+ 957- >5 73 +5 3=45: =5/ 54 + 43/-4 5 + N4575;> C7423=
V6.15.11
6K
