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Neurology

Overview

Neurology is a four week rotation that can be omitted if you choose to spend eight weeks on Family Medicine. The rotation is taken at either the VA or Duke (a decision that is not yours). Neuro patients at the VA are generally on ward 7A, while at Duke they are typically on the fourth floor, either in the ICU, the "stroke unit" (intensive nursing on the regular ward floor), or regular ward rooms. The hours are usually 7-8AM through 5-6PM, depending on the team, including weekends. Call is every fourth night, and is taken with the other student on your team. VA students take call from home.

Teams

The team consists of an intern (most are medicine interns), and a neuro JAR. The chief resident floats in and out. Rounds are made first thing in the morning with an attending. Students always present. There is usually not any pre-rounding with the JAR beforehand, but that depends on the team.

Schedule

AM rounds with the team and ward floor scut is the only thing you do every day. Neuro has several different conferences. There is a chief conference (students and chief only) every week to review basic concepts (e.g., neuro exam). Stroke rounds occur every week, and consist of student presentations (one per week) with considerable pimping of the students. Attending rounds are held once a week and consist of a single student presentation, also with considerable pimping. There are also various lunch conferences, where you eat free, and morning conferences, which students usually do not attend. Clinic is an afternoon option with the attending(s) of your choice (recommended if you are gunning for honors). Finally, there is also a weekly late afternoon M&M conference for all attendings, but students rarely attend.

SOAP notes

Students write SOAPs, admission orders, daily orders, and some discharge papers. The neuro exam is generally written in full for every SOAP note:

 

Mental status

orientation to person, place, purpose,

names, repeats, follows commands without R/L confusion

names President

spells WORLD forwards and backwards

speech

judgment, similarities

memory: __/3 at 0', __/3 at 5'

calculations, serial 7's

finger praxis

graphesthesia

stereognosia

finger agnosia

constructional praxis

Cranial nerves

pupils, visual fields, extraocular movements

facial sensation

masseter strength: R __/5, L __/5

hearing (Weber, Rinne)

palate, uvula, gag response

SCM/trap strength: R __/5, L __/5

tongue protrusion: R __/5, L __/5

Motor function

bulk, tone, strength

muscles tested - deltoids, biceps, triceps, wrist extensors, wrist flexors, finger extensors, finger flexors, interossei, opponens, iliopsoas, quads, hamstrings, tibialis anterior, gastrocs

Deep tendon reflexes

biceps

triceps

brachialis

patellar

ankle

plantar

Coordination

finger-to-nose

rapid alternating movements

heel-to-shin

gait/station

Sensory

light touch

pin point

proprioception

vibration

temperature

Grading

There is one written exam, consisting of six to eight essay questions (e.g.,, given a pt's symptoms, discuss most likely diagnoses, relevant anatomy, and treatment). Other grading is based on ward performance, presentations, etc. There is a grading team, which theoretically consists of everybody except patients. The chief and JARs generally have the most to say, while attendings are occasionally present.

Procedures

The neurology rotation is your chance to learn to do lumbar punctures. Always ask if you can do the LP, especially on your own patients. As a general guideline, a safe place to do an LP is between L4 and L5. This is easily determined by drawing a line between the iliac crests - this will intersect the spine somewhere around L4 or the space directly beneath.

Texts

Neuroanatomy is key. Try to read through Neuroanatomy Made Ridiculously Simple before the rotation begins. It does not take long and is worth the effort. A general neuro text may be helpful (e.g., Adams) but expensive; an alternative is to use the copy in the library . Key cards to carry around include those that outline somatic and cranial innervation, blood supply, seizure medications and related side effects.

Tips

*For any presentation, do the entire neuro exam just before the presentation and be prepared to justify anything you say with the finding you observed.

*Memorize not only the neuro exam but the ORDER of the exam, which seems to very important to the neuro staff.

*Go to clinic with an attending of your choice-otherwise you will not know headaches, fibromyalgia, carpal tunnel syndrome, back pain, etc.

*Frequently look up and cite papers.

*Know neuroanatomy, especially blood supply. Know cranial nerves better than the back of your hand.

*Fight for the opportunity to do LPs.

*Attend as many extra conferences as you can.

*Know indications and side effects for seizure meds.

*Know aphasias and what they mean.

If you would like to add an announcement or suggest any other changes, please contact Ryan Hick, MSI.
This page was last updated 6/20/01.