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  1. 1. Neurology Neurology Course Director Dr. Adrian Jarquin-Valdivia 6-0060 Course Coordinator Linda Hurt MCN A-1106 6-1567 Course website 29
  2. 2. Neurology The Basics Lectures consist of didactic teaching as well as case presentations and exposure to diagnostic techniques, the goal of which will be to help 3rd yrs to master basic neurology topics such as stroke, coma, epilepsy and to become comfortable with the neurologic exam. In the works are teaching sessions on Neuroimaging. Geography 6 North - Main Neurology floor 5 North - Neuro ICU A1133 MCN: Chairman's conference room AA-1206 MCN: Sloan Conference Room Resources Some students use notes/handouts from the Neuro lectures to study for the Neuro exam. They can be supplemented with old Neu- roanatomy notes from Dr. Norden's class. The neuro website also has powerpoints, notes and podcasts. This combination seemed to be sufficient and had the added bonus of being FREE. Another useful source of reading would be the Neurology chapters from a large medicine text like Harrison's. In fact, Dr. Valdivia once said that Harrison's was the best neurology book out there. Make sure you check out the library website, as PreTest Neurology is available online free of charge. Other recommended books to supplement your learning and assist you in preparing for the exam include: - Blueprints in Neurology is an excellent resource for this rotation. It is inexpensive (~$30) and covers all of the important topics for a quick reference. It is about 200 pgs and is very helpful when studying for the Neuro exam. Probably the most commonly used book on this rotation. - Clinical Neurology, 3rd Edition (Arnold) by Fowler and Scadding ($50): This text is 550 pages but well worth it for the medical student interested in neurology. There is more information in here than you will need for the shelf exam but if you know this book cold you will be well prepared for Valdivia's infamous pimping sessions. Up to date and 30
  3. 3. Neurology a surprisingly pleasant read, in my opinion it is superior to Aminoff's (below) but it will probably take you longer to read. - Clinical Neurology (Appleton and Lange) by Aminoff, Greenberg, and Simon ($30-40): This book is 300+ pages of fairly easy reading. Should be thorough enough for anything that might show up on the exam and is also helpful for reading up about patients. - Neurology Secrets by Rolak ($39): Good amount of knowledge for the medical student. Organized to provide a basic overview of all aspects of neurology with questions actually asked by attendings. A very interesting neuro trivia section at the end (but hardly a reason to buy the book). - Neurology (House Officers Series) by Weiner, Levitt ($20-30): This book is 200+ small pages and is concise, readable, and thorough enough for the exam. Quick, easy reading and portable. - Neurology 4th Ed 800 Questions and Answers by Giesser et al. ($40): for those of you who learn by doing questions or for those with an interest in neurology as a career, this is a good book. - Neurology Recall by Miller and Fountain ($27): a good book in the typical Recall style, but not extensive in the amount of detail. - Appleton and Lange Neurology Questions for USMLE Step II (~$35): a useful way to prepare for the kinds of questions that might be asked on the exam. Expectations Conferences/Lectures Student Lectures (M W 12pm - 2pm MCN A0131) - Covering different topics in neurology. There is often lunch provided. There are also two neuro exam conferences during which you will master the different aspects of the neuro exam, including the coma exams. These are on the first Tuesday and Thursday at 4PM. During the last week of the clerkship, there is a Clinical Vignette Conference where cases are read and discussed. Stroke Conference (Tuesday 1 pm A0131 MCN) - During this time one student from the stroke service (plan this in advance!) presents a stroke case to the group for discussion. Again, bring a copy of the H&P, labs, and whatever scans are available if you are the one 31
  4. 4. Neurology presenting. The group usually consists of Dr. Ribeau and the other rotating students. It usually involves a discussion of localization of the lesion, possible etiologies of the stroke (hemorrhagic vs. embolic), and therapy. Some non-stroke cases may also be presented if stroke was a major diagnostic consideration (e.g., a patient with glioblastoma that presented with R-sided hemiparesis and aphasia). uVIEW1 Program (TBA times) - Diagnostic modalities are demonstrated and discussed with an attending. Topics include EMG, EEG, sleep studies, botox injections, and ultrasound. These sometimes are canceled or rearranged. Students’ Chairman's Conference (3rd and 5th Thursday, 1-2pm, Chairman’s conference room) - These conferences are with Dr. Macdonald, the Dept. Chairman. Students will be asked to present 2 interesting cases with a clear diagnostic answer for discussion. Students on each service should decide ahead of time who will present so that they will arrive prepared. It is important to communicate with your classmates so that someone doesn't have to scramble at the last minute. Have an H&P, labs, and whatever scans you can get your hands on. Tthe computer in there can access the PACS system for radiographs. Make sure you pick cases that are didactic and you know the diagnosis. Grand Rounds (F 8-9am, 1220 MRB III) - Breakfast is usually provided. Sometimes the presentation is by VUMC faculty, and sometimes by visiting professors. Residents Chairmans conference (Tuesdays at 11am in Chairmans conference room A1133 MCN) - One or two cases are discussed with the residents. This conference is geared toward the residents, but can be helpful for the medical students. Emphasis placed on differential diagnosis. Call Students make up their call schedule at the beginning of the rotation. You need to have someone on call every day of the rotation including weekends. Call lasts until 12am on weeknights and begins at 8am on weekends. Many residents will let you go home when you have seen a patient or by 10 pm. Keep in mind that you will still be expected to stay until 5 pm then next day, so try to plan accordingly. 32
  5. 5. Neurology Generally students will each have 4-5 call nights during the 4-week rotation. Your job is to write an H&P for 1-2 pts on call and present to your resident/attending. Some residents will let you work up a patient on your own in the ED, but others may want to see the patient with you. You will also cover some patients at the VA. Grades and Evaluations On this rotation you will be evaluated by attendings/residents you work with the most. In addition, you will be required to hand in one H&P every Friday to your attending for evaluation. Finally, the NBME exam consists of 100 multiple choice questions and is given the last day of the rotation. This is a very difficult exam, so don't be discouraged by it if you feel you didn't do well! The person scoring the highest on this test each rotation is given an award by the Neurology Department. The Services The Neurology rotation is designed as a five and a half week rotation, with students splitting their time between two of the following different services. VA The VA rotation focuses on three areas: inpatients, consults and clinics. There is typically one junior level resident and one attending as well as a senior level resident who primarily does consults. The inpatient part is similar to other inpatient services, see your patient and write notes in morning. Consults are usually hit or miss, but you only do them when you are not in clinic. Each attending covering the services has their own expectations. Some like to talk if there are no patients, others let you go home. You must attend the clinics in the 3rd floor of the VA. This is mandatory. They are on M, W and F mornings 8:30-12 and T and TH afternoons 1-5. You will usually be working with Drs. Fang, Davis, Moots, and Wiley. You see patients and present them, then write a note on the VA computer. The VA clinic gives you the rare opportunity to be the first to work up a patient for a particular problem, present them to an attending and 33
  6. 6. Neurology have a stab at formulating a plan. Usually students round on their patients one day out of the weekend. Your schedule will depend on your assigned resident's preferences. If you don't like clinic, avoid this rotation at all costs, as it is much more clinic-heavy than the others. VU Stroke This is a good time to brush up on neuroanatomy, since you'll see a patient's lesions on their scans, and correlate them with their symptoms. Read up on aphasia and common stroke syndromes, since you'll likely get some interesting patients with these. Also take the opportunity to learn about neuroimaging. Things to focus on in notes include the evolution of the patient's neuro exam over time, and their anticoagulation/stroke prevention treatment. Drs. O'Duffy, Kirshner, Ribeau, and Valdivia rotate attending coverage on this service, and all are excellent teachers. Note: It's considered wise to eat and pee prior to rounds with Dr. O'Duffy as she has a fantastic way of connecting with the patients and rounds can take awhile. Dr. Kirschner will be mesmerized by the patient's television unless you TURN IT OFF the minute you enter the room! Dr. Valdivia expects more out of medical students than O'Duffy or Kirschner, but you will learn a tremendous amount from him - rarely will you meet someone so excited about his/ her specialty. Dr. Ribeau is awesome and will give you a lot of responsibilty and will take time to teach you. Going through his lectures from Neuro can help with prepping for teaching sessions with him. Stroke patients tend to stay on this service a long time, so you'll get to bond with them. Days start at 8am at which time you will see your pts and will write the notes. Your work will usually be done by early afternoon; however, the stroke service admits patients until 4:30 daily, so depending on your resident you may have to stick around in case there's an admission. You will round on your patients one day out of the weekend and will usually go home by noon at the latest. VU Inpatient This will be similar to any other ward rotation during which you follow patients, write notes, round with the attending, go to confer- ences, and take call. Your schedule will be completely dependent upon 34
  7. 7. Neurology the residents and attending on service for the month. There is typically an intern, a junior level, and a senior level resident on this service. Usually, you will see 2-4 patients and write notes to be prepared by morning rounds, which varies per attending. All Neurol- ogy teams admit patients until 4:30 pm and then the call team takes over with the admissions. Whether or not you have to stick around until then is up to your team - some will let you go while others want you to stick around the med center but will let you go and read and page you if an admission comes in. Weekends are also resident dependent, but you will likely have to come in one day out of the weekend to round on your patients. VU Consults This is a good time to learn your neuro exam cold, because you will do several H&P's per day on patients with a wide variety of neurologi- cal conditions. The day typically starts at 8:00am. You write notes on any old consults that still have active neuro issues and then do an H&P on all new patients. Be prepared for long hours. Rounds with the attending usually begin late morning / early afternoon and can continue into the evening. Don't make any social plans before ~ 7:00 for these two weeks, but enjoy the variety and the autonomy of forming your own differential diagnosis. The consult team is also responsible for working up all neuro patients in the ED. You will have weekends off on this service. If you like roaming around the hospital examining patients on other services, this rotation will be perfect for you. Child Neurology Students greatly enjoyed this rotation. Hours were 8am - 5pm each day. Some days, the child neurologists do not have afternoon clinic, so neither do you! Patients mainly present with migraine, seizures, and cerebral palsy. You may also get a chance to see some interesting genetic disorders like neurofibromatosis and tuberous sclerosis. Dr. Piña-Garza and Dr. Kilroy are the main physicians you will work with. They are all very experienced, kind, and approachable. This rotation 35
  8. 8. Neurology allows you a lot of autonomy. The physicians let you go in and interview the patient first and then come out and present to them. You will then type up an H & P for each patient you see. It is really a great experience and students as a whole really enjoyed this rotation. At varying times of the year, one student may be on the inpatient/ consult peds neuro service, depending on the numer of studentson the clerkship. Things You Should Know Important abbreviations . . . AAO: awake, alert and oriented EOMI: extra-ocular muscles intact VF: visual fields (full-if grossly normal) PERRLA: pupils equal round and reactive to light and accommodation FNF: finger-nose-finger HTS: heel to shin DTRs: deep tendon reflexes AMS: altered mental status RAMs: rapid alternating movements LE/UE: lower extremity/upper extremity MSE: mental status exam INO: intranuclear opthalmoplegia Terms commonly used to describe… Consciousness: alert, responsive, oriented, awake, lethargic, obtunded, stuporous, comatose. Posture and Motor activity: athetosis - writhing, repetitive movements chorea - ballistic, sudden movements fasciculations - fine twitching of muscle bundles (esp in tongue) dystonia - tonic contraction that is sudden of tongue, neck (torticollis), back (opisthonos), mouth, eyes (oculogyric crisis) tardive dyskinisia - lip smacking, chewing, teeth grinding (usually medication induced) 36
  9. 9. Neurology Definitions Delirium - an altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception (illusions and hallucinations), prominent hyperactivity, agitation and autonomic nervous system hyperactivity; caused by a number of toxic structural and metabolic disorders. Dementia - the loss, usually progressive, of cognitive and intellec- tual functions, without impairment of perception or consciousness; caused by a variety of disorders including severe infections and toxins, but most commonly associated with structural brain disease. Charac- terized by disorientation, impaired memory, judgment, and intellect, and a shallow labile affect. SOAP Note (Neuro-style) Same as your medicine or peds SOAP notes with a special emphasis on the neuro exam meaning that you write one word for everything non-neurologic and a paragraph for the Neuro Exam (see below). NYU med school has a great web site for this: Here you will find everything you ever wanted to know about to do a neuro exam and what it means. Neuro Exam I - for the Responsive Patient This can be divided into six sections- 1. Mental Status: Briefly, if the patient is alert and oriented (to person, time, place, and reason for hospitalization). More formally, you may use the MMSE (mini mental status exam). See the Psychiatry section of the Oar for a detailed explanation of how to perform the MMSE. It may also be useful to do months of the year backward or 20-1 backward. 2. Cranial Nerves: Coffee/cinnamon (I); Pupillary light reflex, fundoscopy, visual fields, visual acuity (II, III); Extraocular motion (III, IV, VI) and always ask about double vision; Sensation and corneal reflex (V); Smile and squint (VII); Hearing and nystagmus (VIII); Say “ah” (IX, X - palate); Shrug and turn your head (XI); Tongue (XII). 37
  10. 10. Neurology 3. Motor: Tone: passively flex and extend the joints. Strength: 5 normal, 4 weak, 3 lift against gravity but not against resistance, 2 move joint but not against gravity, 1 can contract but not move. 4 is common, so use 4- and 4+. Test deltoid, biceps, wrist extensors, interossei, psoas, quadriceps, and ankle extensors. Patients with disorders involving their strength will need a more detailed motor exam). You can test for proxmial weakness as well as look for tremor and drift by having a patient raise their arms, palms up, and close their eyes. Posture: while patient sits, walks, and stands. Abnormal movements: resting tremor, athetosis, etc. Tremor: postural vs. intention. 4. Muscle Stretch Reflex: Depressed reflexes are commonly seen in sensory neuropathies, muscle disease, and motorneuronal loss. Increased reflexes may be the result of corticospinal tract lesions. Different attendings have different numbering systems, so don't just say “2.” By spinal level: Ankle: S1-2 Knee: L3-4 Biceps: C5-6 Brachioradialis: C5-6 Triceps: C7-8 5. Coordination: Rapid repeating movements (one hand in the other) and Rapid alternating movements (top and bottom onto other hand) test the pyramidal and extrapyramidal systems. Finger-to-nose and heel-knee-shin test for cerebellar lesions. Fine finger movements tests all motor systems. Toe-tapping: tap toe while heel planted. Also hold arms outstretched, eyes closed touch nose x3. Stance and Gait: Both wide and narrow stance. Then have patient close eyes and look for a Romberg; Gait: heel and toe walking, then “tightrope walking.” 6. Sensory: Always do this part of the exam LAST because it is the most subjective part and if you've done the rest of the exam you can have a better idea how to interpret these so-called “soft signs.” Never base a diagnosis on soft signs alone. 7. Autonomic: not commonly done but if you pick up a problem 38
  11. 11. Neurology here you will be star - orthostatics, Valsalva (measure change in pulse rate). Neuro Exam II - for the Unresponsive Patient The Physical Exam will be very different if you have a patient that is unresponsive or comatose. Because this exam may appear harsh to the family, do not do these things when the family is present. Level of responsiveness: to voice or to noxious stimulus (start with pressure on the supraorbital nerve or the sternal rub, proceed to pressure on nailbeds using your tuning fork). For a more formal approach with head trauma cases, see the Glasgow coma scale (EVM456). Cranial Nerves: PERRL, blink to threat (quickly move hand toward each eye to see if patient will reflexively blink to test gross visual field cuts) or corneal reflex with a drop of saline, “Doll's eyes” or oculocephalic reflex by quickly turning patients head to the side to see if eye movement lags behind head movement (normal). If the patient's eyes don't move, repeat Doll's eyes using up/down nodding. You may also test this reflex by injecting a syringe full of cold water into the person's ears (normal response is slow movement of the eyes toward the injected ear; emesis is common). Gag/cough reflex by advancing suction tubing (if patient is on a vent) to back of orophar- ynx or just ask the nurse if he/she is gagging. Neurosurgeons will simply press on the suprasternal notch, with almost effective a response as advancing the suction tubing without the fear of extubating. Motor: Check tone in all four extremities. See if the patient will withdraw from pain (tuning fork on nailbed). DTR's: All four extremities. Pathologic Reflexes: (see below for further description) a) Corticospinal: Babinski, Chaddock maneuver, Bing response, Hoffman reflex, clonus b) Frontal release: Grasp, glabellar, snout, rooting, palmomental Sensory, Proprioception, Gait, Language, and Coordination cannot be tested when the patient is unable to cooperate with the exam. 39
  12. 12. Neurology Other Useful Tools 1) Apraxias: have patient show you how to comb hair, hammer a nail, saw wood, install a lightbulb 2) Spatial neglect: have patient draw a clock (8:20), copy a flower 3) Language: spontaneous speech, naming objects, repetition, comprehension, reading, writing A Useful Neurology Review of Systems 1) Changes in mood, memory, or concentrating ability 2) LOC, fits, seizures 3) Undue suffering from headaches 4) Changes in smell, taste, sight, hearing 5) Difficulty talking, chewing, swallowing 6) Numbness, tightness, pins and needles, or tingling or burning sensations in the face, limbs, or trunk 7) Weakness, stiffness, heaviness, or dragging of arms or legs 8) Difficulty using your hands for skilled tasks (writing, typing, dressing) 9) Unsteadiness or difficulty walking 10) Loss of bladder or bowel control? Pathologic Reflexes: Corticospinal Tract Signs - Babinski response: fanning of the toes (plantar response, PR) following stroking the bottom of the foot. If these are in any way in doubt, always examine 4-quadrant abdominal reflexes (umbilicus should respond - this is lost in upper motor neuron lesions) - Chaddock maneuver: scratch the lateral foot (look for PR) - Bing response: light pinpricks to dorsolateral foot (PR) - Hoffman reflex: snap the distal phalanx of middle finger. Subsequent thumb flexion is pathological - Clonus: test the ankle Pathological Reflexes: Frontal Release Signs Frontal release signs signify dysfunction of the frontal lobes. Produce very subtle findings unless they are severe, so these reflexes are important to look at in patients with memory difficulty, 40
  13. 13. Neurology personality change, anosmia (olfactory groove meningioma with frontal lobe damage). The most common frontal release signs are: - Grasp: the most specific sign of frontal lobe dysfunction. Stoke the palm and look for hooking of the fingers or a firm grasp - Glabellar: blinking of the eyes in response to tapping between the eyebrows. One or two blinks is normal but if you patient keeps blinking there is a problem - Palmomental: contraction of the depressor angularis oris after stimulating the palm Glascow Coma Scale Range: 3-15 points - “EVM456” Eye opening Best motor response spontaneously 4 obeys verbal command 6 to verbal command 3 localizes pain 5 to pain 2 flexion/withdrawal 4 no opening 1 decorticate posturing 3 Best verbal response decerebrate posturing 2 oriented/converses 5 no response 1 disoriented/converses 4 verbalizes 3 vocalizees 2 no response 1 41
  14. 14. Neurology Sample SOAP Note 5/29/07 07:30 Neuro VMSIII HD#3 S: Patient complains of constipation this AM. Received enema, Mg citrate last night with only small stool output this AM. Patient reports headache last night; pain relieved by ibuprofen. Continues to complain of R-sided weakness that is unchanged from yesterday. O: VS: HR:76, BP:150/84 (142-160/72-82), RR:18, Tmax:98.5, Tc:96.5 I/O: 2350/2290 GEN: asleep, easily arousable, well-appearing, NAD CHEST: CTA B, moving air well. CV: RRR, no m/r/g ABD: soft, NT, ND, NABS EXT: no c/c/e, 2+ DP pulses B. NEURO: MS- Awake, alert and oriented X3 CN- PERRLA, EOMI, tongue midline, face asymmetric with R upper and lower facial weakness, sensation grossly intact. Speech mildly dysarthric. MOTOR- Strength 4/5 RUE, 4+/5 RLE, 5/5 LUE, 5/5 LLE. Normal tone and muscle mass of all four extremities. DTR- 2+ bilaterally in BR, biceps, patellar. SENS- No deficits in light touch, pinprick, proprioception, or vibration. COORD- FTN nl, HTS nl B. Gait exam deferred. LABS: LDL 160, HLD 37, TG 180. A/P: 52yom with chronic HTN, hyperlipidemia, presents with R-sided weakness, MRI revealed small L basal ganglia hemorrhage. 1. NEURO: PT/OT Consult. Pt is currently stable and has shown some improvements in strength since admission. Continue to monitor for changes. 2. CVS: Pt continues to be hypertensive. Will continue Norvasc at 10mg po qday and will increase lisinopril from 10 mg qday to 20mg qday. Pt also has elevated fasting lipid levels; begin statin. 3. FEN/GI: Cardiac diet. 4. PAIN: Motrin PRN. 5. PROPHYLAXIS: Pepcid, SCD's/Teds. 42
  15. 15. Neurology Key: HD-hospital day, NAD-no apparent distress, CTA B-clear to auscultation bilaterally, NT-non-tender, ND-non-distended, NABS-nomal active bowel sounds, DP-dorsalis pedis, PERRLA-pupils equal round reactive to light and accommoda- tion, RUE-right upper extremity, RLE-right lower extremity, LUE-left upper extremity, LLE-left lower extremity, BR-bracthioradialis, FTN-finger to nose, HTS- heel toe shin, yom-year old male, HTN-hypertension, PT/OT-physical therapy/ occupational therapy, PRN-as needed, SCD-sequential compression devices 43
  16. 16. Neurology 44