Goals and Objectives

Neurology Elective

Goals:

The educational goals of the rotation in Neurology for the house officer are to 1)develop the ability to independently evaluate, treat, and monitor common neurological conditions, 2)to acquire the knowledge of the underlying processes that contribute to the pathophysiology of the different neurological diseases, and 3)to describe the research tools for studying the underlying mechanisms of different neurological disorders.

Objectives:

A. Medical knowledge and patient care

Internists commonly encounter patients with various neurological disorders including those related to changes in strength, sensation and movement. The basis of diagnosing neurological disorders is a careful, comprehensive history and physical exam. Neurologic disorders commonly illustrate the deleterious effects of alcohol excess trauma and nutritional deficiencies. Various occupational and environmental toxic exposures can cause neurological disorders. Ethical issues involving continuation and intensity of care are routinely encountered in the care of the comatose patient.

Diseases Mix and Topics Emphasized

1. Mastering the neurologic examination.

2. Determining whether a neurologic problem is located in the neuroaxis or periphery.

3. Distinguishing acute and subacute CNS conditions from chronic problems.

4. Evaluation and management of cerebrovascular disease.

5. Seizure disorders including status epilepticus, etiology and treatment.

6. Evaluation and management of coma.

7. Acute encephalopathy.

8. Central nervous systems infections including meningitis, encephalitis and abscess.

9. Neurologic complications of cancer, both local and systemic.

10. Guillian-Barre’ Syndrome

11. Acute spinal cord syndromes including transverse myelitis and cord compression.

12. Acute and subacute neuromuscular disorders.

13. Syncope.

14. Headache, including migraine and chronic daily headache.

15. Proper use of neurological imaging and other diagnostic modalities.

16. Evaluation of dementia.

17. Multiple sclerosis.

18. Back and neck pain.

19. “The Dizzy Patient”.

20. Sleep disorders.

 

Procedures and Services

Residents will be exposed to the proper utilization of EEGs, electromyography and nerve

conduction studies, muscle and nerve biopsy and interpretation of spinal fluid studies.

 

B. Other competencies

1. Demonstrate practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems based practice through interaction with patients,attendings, and other health care personnel and through delivery of appropriate subspecialty care in a variety of venues.

 

Learning venues:

Patient Characteristics and Types of Clinical Encounters

Patients evaluated on the neurology rotation range from adolescent to geriatric. Disorders may be subtle and slowly progressive, stable and inactive or acute and life threatening. Patients from all socioeconomic categories are encountered.

 

Outpatient Neurology clinic

The resident assists with the evaluation and management of patients in the private neurologist’s office, supervised by on-site faculty neurologists.

Resident will be assigned to attend several outpatient clinics per week.

Inpatient consultations:

Residents will follow inpatient consults along with the inpatient consult attending.

Residents interact daily with the attending during patient rounds. Residents also have regular didactic sessions with the supervising attending on assigned topics as well as those encountered during patient rounds. Self-directed reading is expected on those topics encountered by the resident. The attending neurologist observes and critiques the resident while undergoing history and exam during both inpatient and outpatient settings.

.

Reading List

A. Encephalopathy

1. Becker K, Ulatowski J. Disorders of consciousness and equilibrium: The comatose

patient. Current Therapy in Neurologic Disease. 1-4.

2. Practice parameters for determining brain death in adults. Neurology 1995;45:1012-1014.

3. Booth C, Boone R, Tomlinson G, et al. Is this patient dead, vegetative or severely

neurologically impared? Assessing outcome for comatose survivors of cardiac arrest.

JAMA 2004; 291(7):870-879.

4. Levy D, Caronna J, Singer B, et al. Predicting outcome from hypoxic-ischemic coma.

JAMA 1995;253;10:1420-1426.

5. Mangano D, Mangano C. Perioperative stroke; ecephalopathy and central nervous system

dysfunction. J Intensive Care Med 1997;12:148-160.

 

B. Stroke

1. Adams H, Adams R, Brott T, et al. Guidelines for the early management of patients with

ischemic stroke: A scientific statement from the Stroke Council of the American Stroke

Association. Stroke 2003;34:1056-1083.

2. Straus S, Majumdar S, McAlister E. New evidence for stroke prevention: Scientific

Review JAMA 2002;288(11):1388-1395.

3. Straus S, Majumdar S, McAlister E. New evidence for stroke prevention: Clinical

Applications. JAMA 2002;288(11):1396-1398.

4. Donnan G, David S. Controversies in stroke. Stroke 2002;33:2137-2140.

5. Adams H. Patent foramen ovale: paradoxical embolism and paradoxical data. Mayo Clin

Proc 2004;79:15-20.

6. Horton S, Bunch T. Patent foramen ovale and stroke. Mayo Clin Proc. 2004;79:79-88.

7. Hiott B, Lentz S. Prothrombotic states that predispose to stroke. Current Treatment

Options in Neurology 2002;4:417-425.

8. Muir K. Secondary prevention for stroke and transient ischaemic attacks. BMJ

2004;328:297-298.

9. Hemphill C. Acute management of intracerebral hemorrhage. Stroke Rounds 2003;1(4).

 

C. Seizure

1. Manno E. New management strategies in the treatment of status epilepticus. Mayo Clin

Proc 2003;78:508-518.

2. Herman S. Single unprovoked seizures. Current Treatment Option in Neurology

2004;6:243-255.

3. Kaufmann H, Bhattacharya K. Diagnosis and treatment of neurally mediated syncope.

The Neurologist 2002;8:175-185.

 

D. Headache

1. Diamond M. Emergency room treatment of migraine headache. Current Treatment

Options in Neurology 2002;4:351-356.

2. Lucas S. Initial abortive treatments for migraine headache. Current Treatment Options in

Neurology 2002;4:343-350.

3. Wheeler S. Antiepileptic drug therapy in migraine headache. Current Treatment Options

in Neurology 2002;4:383-394.

4. Moore K. Management of chronic headache in the era of managed care. The Neurologist

1997;3:209-240.

 

E. Dementia

1. Petersen R. Mild Cognitive Impairment.

2. Corey-Bloom J. Alzheimer’s Disease.

3. Knopman D. Vascular Dementia.

 

F. Neuromuscular Disease

1. Bromberg M, Smith AG. Toward an efficient method to evaluate peripheral neuropathies.

J Clin Neuromus Dis 2002;3:172-182.

2. Smith AG, Bromberg M. A rational diagnostic approach to peripheral neuropathy. J Clin

Neuromus Dis 2003;4:190-198.

3. Al-Shekhlee A, Chelimsky T, Preston D. Review: small fiber neuropathy. The

Neurologist 2002;8:237-253.

4. Van der Meche F, Van Doorn P. Guillain-Barre Syndrome. Current Treatment Options in

Neurology 2000;2:507-516.

5. Briemberg H, Amato A. Dermatomyositis and polymyositis. Current Treatment Options

in Neurology 2003;5:349-356.

6. Bolton C, Young GB. Critical illness polyneuropathy. Current Treatment Options in

Neurology 2000;2:489-498.

7. Diagnosis of cervical root and peripheral nerve lesions affecting the arm.

8. Nerve root and peripheral nerve lesions affecting the leg.

9. Keesey J. Clinical evaluation and management of myasthenia gravis. Muscle Nerve

2004;29:484-505.

G. Multiple Sclerosis

1. O’Conner P. Key issues in the diagnosis and treatment of multiple sclerosis. Neurology

2002;59(6)(3):1-33.

H. Encephalitis/Meningitis

1. Acute Bacterial Meningitis

I. Movement Disorders

1. Suchowersky O, Furtado S. Parkinson’s Disease: Etiology and Treatment.

2. Margery M. Tremor Disorders.

3. Horn S. Drug-Induced Movement Disorders.

4. Bertoni J, Prendes J, Sprenkle P. Long-term medical treatment for Parkinson’s Disease.

Current Treatment Options in Neurology 2001;3:495-506.

5. Rubino F. Gait Disorders. The Neurologist 2002;8;254-262.

 

Competency Evaluation:

Residents will be expected to attend all assigned clinic sessions and perform all inpatient consultations, complete assigned readings, demonstrate satisfactory competence by performing a detailed neurologic examination, and demonstrate acceptable skill in the appropriate selection of studies to evaluate neurologic conditions. Attending neurologists will complete an end of the month evaluation form with the resident.

To complete the neurology rotation, the resident must:

A. Receive satisfactory end of rotation evaluation by the supervising faculty member.

B. Complete assigned readings.

C. Attend all outpatient clinic activities (excluding scheduled time away, required clinics and emergencies).

D. Perform all inpatient neurologic consultations on the floor as well as the intensive care unit with satisfactory skill.

E. Demonstrate satisfactory skill in the performance of a detailed neurologic examination.

F. Demonstrate satisfactory skill in performing the neurologic examination of the comatose patient.

 

 

Outcomes Assessment:

The educational success of our elective in neurology will be based upon two criteria: 1)neurology subsection scores on the in-service examination of all residents who have completed the elective and 2)neurology subsections on the ABIM certifying examination in internal medicine taken by medical graduates. Our goal is for all residents scoring at the 50^th percentile or higher.