Neurology
This document has been endorsed by the American Academy of Family Physicians and
the American Academy of Neurolo...
iii. Meningitis and Encephalitis
                 iv. Status epilepticus
                  v. Central nervous system traum...
10. Myelography
                                  11. Carotid ultrasound
                                  12. Sleep study...
1.Thrombolytics

                a.Indications and use
                b.Risks and benefits
B.   Hemorrhagic stroke
C.   V...
1.Generalized at onset seizures
       2.Simple partial seizures
       3.Complex partial seizures
       4.Treatment

   ...
c.Intrinsic lesions
•   Sleep disorders
•   Disorders of peripheral nerve, neuromuscular junction and muscle
        a.Mus...
•   The genetic basis of certain neurologic disorders as they affect the patient and
       family and education of the fa...
society, and the profession; and a commitments to excellence and on-going
          development
       B. Demonstrate a co...
Implementation of these curriculum guidelines is best achieved within the capabilities of
the particular residency program...
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Neurology.doc

  1. 1. Neurology This document has been endorsed by the American Academy of Family Physicians and the American Academy of Neurology and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine. The goal of these guidelines is to sensitize the family practice resident to neurologic disease and familiarize residents with its particular place in the overall practice of family medicine. Neurologic problems are estimated to comprise 10 to 15 percent of a family physicians workload. The specialty of family practice is vitally interested in all aspects of neurologic disease. History-taking in neurology and performance of the neurologic examination are essential skills. Emphasis on good diagnostic and therapeutic skills and appropriate consideration of biopsychosocial factors must be included in the curriculum. Patient Care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: A. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families B. Take a supportive and compassionate approach to the care of the patient with neurological disease, especially in the case of patients with chronic disease a. Recognition of the importance of family, home, and social support in the overall life of patients with neurologic disease. B. Take an accurate and effective neurological history C. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment D. Develop and carry out patient management plans (including management and recognition of the prevalent and treatable diseases under “Medical Knowledge”) taking into consideration the severity and need for immediate expert assistance and referral. a. Understanding the role of a neurologic specialist and the implications of special testing in patients with neurologic disease and the implications to the patient of test results b. Managing the prevalent and treatable conditions listed above under "Knowledge," with consultation as appropriate c. Managing emergent neurologic problems and obtaining urgent consultation when appropriate, including: i. Stroke ii. Coma
  2. 2. iii. Meningitis and Encephalitis iv. Status epilepticus v. Central nervous system trauma vi. Increased intracranial pressure vii. Acute visual loss viii. Rapidly progressive neurologic deficit ix. Neurologic respiratory failure x. Acute weakness xi. Altered mental status d. Understanding the psychologic and rehabilitation aspects of patient management, especially for chronic or long-term neurologic conditions E. Counsel and Educate patients and their families on the prevention of neurologic disease F. Use Information Technology to support patient care decisions and patient education G. Provide health care services aimed at preventing health problems or maintaining health a. Prevention of neurologic disease b. Work with health care professionals, including those from other disciplines, to provide patient-focused care H. Perform competently all medical and invasive procedures considered essential for the area of practice a. Evaluation skills i. Performance of specific procedures and interpretation of results 1. Recognizing and defining the neurologic problem 2. Performing a complete neurologic and mental status examination, Glascow coma scale and pediatric developmental exam 3. Using clinical knowledge to localize the lesion and generate a differential diagnosis 4. Formulating a rational plan of further investigation and management 5. Knowing the indications, contraindications, risks and significance of ancillary tests 1. Lumbar puncture and its performance 2. Electroencephalogram 3. Visual, brain stem auditory and somatosensory evoked potentials 4. Nerve conduction study and electromyography 5. Muscle and nerve biopsy 6. Computed axial tomography with and without contrast 7. Magnetic resonance imaging with and without contrast 8. Magnetic resonance angiography 9. Angiography
  3. 3. 10. Myelography 11. Carotid ultrasound 12. Sleep study 13. Genetic testing 14. PET scanning 15. SPECT scanning ii. Performance of physical examination in patients from newborns to adults, with emphasis on understanding normal neurologic and motor responses as well as appearance Medical Knowledge Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Residents are expected to demonstrate an investigatory and analytical thinking approach to clinical situations. Residents are expected to know and apply knowledge of neurological disease including: A. Normal anatomy, physiology and anatomic principles that allow localization of neurologic disease B. Normal growth, development and senescence of the nervous system C. Pathologic neurologic disorders to include: 1. Disorders of motor function a. Upper and lower motor neuron disorders b. Incoordination c. Movement disorders 1. Hypokinetic a. Parkinson’s disease b. Parkinson plus syndromes 2. Hyperkinetic a. Athetosis b. Chorea c. Dystonia d. Tics e. Tremor 2. Disorders of sensation a. Central b. Peripheral 3. Disorders of vision a. Visual field defects b. Monocular and binocular blindness c. Diplopia and gaze palsies d. Nystagmus e. Pupillary abnormalities 4. Cerebrovascular diseases a. Ischemic stroke
  4. 4. 1.Thrombolytics a.Indications and use b.Risks and benefits B. Hemorrhagic stroke C. Vasculitis D. Transient Ischemic attacks E. Symptomatic/asymptomatic carotid stenosis F. Aneurysmal disease • Head and spinal cord trauma a. Evaluation b. Management c. Consequences • Multiple sclerosis a. Diagnostic criteria b. Laboratory findings c. Management • Dizziness and disorders of hearing a. Central vs. peripheral hearing loss 1.Acute 2.Chronic • Central vs. peripheral vertigo 1. Acute 2. Chronic 3. Evocative testing (e.g., Hallpike maneuver) • Tinnitus • Disorders of higher cognitive function and communication a. Dementia 1.Differential diagnosis 2.Evaluation 3.Management • Encephalopathy (acute, chronic) 1. Toxic 2. Metabolic • Aphasia, apraxia • Disorders of consciousness a. Syncope b. Epilepsy
  5. 5. 1.Generalized at onset seizures 2.Simple partial seizures 3.Complex partial seizures 4.Treatment a.Medical management with anticonvulsant medications b.Surgical management c.Vagal nerve stimulator • Recognition and treatment of increased intracranial pressure • Stupor and coma 1. Toxic, metabolic 2. Structuraldisease 3. Herniation syndromes • Brain death • Headache a. Migraine and variants b. Cluster headache c. Tension-type headache d. Headache associated with a structural lesion e. Benign intracranial hypertension (pseudotumor cerebri) f. Chronic daily headache g. Emergent headaches 1.Subarachnoid hemorrhage 2.Meningitis 3.Giant-cell arteritis/temporal arteritis • Brain tumors a.Anterior or posterior fossa 1.Primary a.Benign b.Malignant • Metastatic • Infections (meningitis and encephalitis) a.Bacterial b.Viral or retroviral (human immunodeficiency virus) c.Fungal d.Tuberculosis e.Prion disease • Spinal cord disorders a.Anatomy and localization b.Extrinsic compressive lesions
  6. 6. c.Intrinsic lesions • Sleep disorders • Disorders of peripheral nerve, neuromuscular junction and muscle a.Muscular dystrophy b.Peripheral neuropathy c.Mononeuritis multiplex d.Myopathy e.Guillain-Barre syndrome f.Myasthenia gravis g.Plexopathy h.Radiculopathy i.Diagnostic studies (e.g., nerve conduction velocity, electromyograph, muscle biopsy) • Congential disorders a.Brain and spinal cord malformations 1.Arnold-Chiari malformation 2.Meningomyelocele 3.Cortical malformations • Chromosomal abnormalities, (e.g., Down’s syndrome) • Abnormal head growth 1. Microcephaly 2. Macrocephaly (including hydrocephalus) • Aberrant development 1. Development delay 2. Mental retardation 3. Neurodegenerative diseases • Developmental disorders of higher cerebral function a. Mental retardation b. Developmental language disorders c. Learning disabilities (e.g., dyslexia) d. Attention deficit disorder, with or without hyperactivity e. Pervasive developmental disorders (e.g., autism) • Psychiatric disorders mimicking neurologic disease a. Non-epileptic spells (e.g., pseudoseizures) b. Dementia of depression (e.g., pseudodementia) c. Conversion disorder d. Malingering e. Disorders of somatization and hypochondriasis • Principles of pain management a. Pharmacologic agents b. Surgical management
  7. 7. • The genetic basis of certain neurologic disorders as they affect the patient and family and education of the family regarding the benefits of genetic counseling • Neurologic complications of systemic illness • Continuing awareness of potential drug interactions and adverse drug effects, especially in elderly patients Practice-based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to use self-directed learning to further knowledge and competence in neurology by: A. analyze practice experience and perform practice-based improvement activities using a systematic methodology B. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems C. Obtain and use information about their own population of patients and the larger population from which their patients are drawn D. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness E. Use information technology to manage information, access on-line medical information; and support their education F. Facilitate the learning of students and other health care professionals Interpersonal and Communication Skills Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: A. Create and sustain a therapeutic and ethically sound relationship with patients B. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills C. Work effectively with others as a member or leader of a health care team or other professional group Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: A. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients,
  8. 8. society, and the profession; and a commitments to excellence and on-going development B. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices C. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities 1. An understanding of the neurologic disabilities of elderly patients, and the importance of assessing, restoring and maintaining their functional capacity Systems-Based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: A. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice B. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources C. Practice cost-effective health care and resource allocation that does not compromise quality of care a. Formulating a diagnostic and management plan and assessing the need for expert advice with an awareness of the risks, benefits and costs of this evaluation 1. Advocate for quality patient care and assist patients in dealing with system complexities 1. Support of the patient through the process of consultation, neurologic evaluation, treatment, rehabilitation and long- term care. B. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance a. Managing the family and psychosocial issues that accompany the long- term care of patients with debilitating neurologic conditions, including home and community care, the utilization of community resources, the use of a multidisciplinary team and the primary role of the family physician as coordinator of long-term care Implementation
  9. 9. Implementation of these curriculum guidelines is best achieved within the capabilities of the particular residency program and at the discretion of the residency director. The resident must have the opportunity to diagnose and manage, under supervision, patients with neurologic disorders as well as those with signs and symptoms possibly referable to the nervous system, with emphasis neurologic consultation should supplement the educational process in the care of patients with problems referable to the nervous system. Resources 1. Merritt, H.H., and Rowland, L.P. 2000 Textbook of Neurology. Tenth Edition. Philadelphia, PA: Lippincott, Williams and Wilkins. 2. Victor, M., et. al.. 2000. Adams and Victor’s Principles of Neurology. Seventh Edition. McGraw-Hill. 3. Bradley, W.G. et al., 1999 Neurology in Clinical Practice. Third Edition. Butterworth-Heinemann. 4. Patten, J., 1996 Neurological Differential Diagnosis, Second Edition. Springer. 5. Samuels, M.A. 1999 Manual of Neurologic Therapeutics. Sixth Edition., Lippincott, Williams & Wilkins. 6. Weiner, W.J., Goetz, C.G. 1999 Neurology for the Non-neurologist. Fourth Edition. Lippincott, Williams & Wilkins. 7. Wilkinson, J.L. 1998 Neuroanatomy for Medical Students. Third Edition. Butterworth-Heinemann. 8. Kandel, E.R., et al. 2000 Principles of Neural Science. Fourth Edition. McGraw- Hill. 9. DeJong, R.N., Mcgee, K.R. 1992 The Neurologic Examination. Fifth Edition. Harper & Rowe. 10. Gelb, D.J. 1995 Introduction to Clinical Neurology. Butterworth-Heinemann. 11. Plum, F., Posner, J.B. 1980 The Diagnosis of Stupor and Coma. Third Edition. F. A. Davis & Co. 12. Simon, R.S. et al. 2000 Clinical Neurology. Fourth Edition. Lange Medical Books, McGraw Hill. Useful Websites AAN: http://www.aan.com/ emedicine Neurology: http://www.emedicine.com/neuro/index.shtml Neuromuscular Disease Center: http://www.neuro.wustl.edu/neuromuscular/ Mental Health, CNS and Neurological Diseases Information Center: http://pharminfo.com/disease/mental/html Whole Brain Atlas: http://www.med.harvard.edu/AANLIB/home.html Adapted from AAFP and ACGME 2002

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