Download Welcome to your Neurology Rotation

Welcome to your Neurology Rotation!
We look forward to working with you during your neurology rotation. This rotation
should give you the opportunity to gain exposure to a wide variety of neurological
problems. We hope that you will find it to be a valuable and enjoyable learning
opportunity.
During your neurology rotation, you will join either the neurology inpatient service and
be responsible for the care of the neurology inpatients which includes patients brought in
under the Acute Stroke Protocol or the neurology consultation service and be responsible
for any consultation requests from the emergency department or from other services.
You will be expected to know your assigned patients’ issues well, follow them on a daily
basis and write notes daily. Be prepared to present their histories, physical examination,
investigations and management plan to the Attending +/- neurology fellows on rounds.
Neurology Faculty
Dr Donald Brunet
Dr Michel Melanson
Dr Giovanna Pari
Dr Allison Spiller
Dr Stuart Reid
Dr Al Jin
Dr Sean Taylor
Dress Code
 There is no formal dress code but it is expected that you will dress professionally
but also comfortably. Your shoes must conform to hospital policy (they must be
closed with at least a strap around heel and not higher than 1 ½ inches)
Tools of the Trade
 In order to do an adequate neurological examination, it is necessary for you to
have a reflex hammer and a tuning fork (128 hz). Opthalmoscope and flash lights
are usually available on the ward, in the emergency department and in the clinics.
Stroke Unit
 The neurology service also runs a 10 bed Acute Stroke Unit which uses a
multidisciplinary team to enhance patient outcomes. A Handbook called “Stroke
Unit House Staff Resource” has been developed to assist you in looking after the
stroke patients from the time of initial assessment and throughout their stay at
KGH. This handbook is available on the ward or through Darlene Bowman, the
Stroke Specialist Case Manager (pager 536-7579)
The ward neurologist “on service” typically covers the team for 1 to 2 week intervals,
starting on Mondays and is the “admitting” neurologist for patients during their weeks of
service. The neurology ward team is responsible for caring for neurology inpatients
(ranging from 5-15 patients) and for attending any Acute Stroke Protocols.
The neurology consultation team is responsible for completing any inpatient or
emergency department consultations and following them throughout their hospitalization.
Most of the time, the neurologist covering the consultation service will be different from
the neurologist covering the ward patients but not always. The most senior off service
resident on the consultation team or the neurology resident (if available) will oversee the
housestaff and divide up the consults. The senior resident will also get paged if the Acute
Stroke Protocol has been activated.
First Day
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On the first day of your ward rotation, you can meet the housestaff on Kidd 7 at
8:00 am.
There is not always a senior resident on the ward to oversee things so you and
other housestaff can divide up the patients yourselves.
It is imperative for efficient functioning of the ward that you talk to the charge
nurse at 08:00 each morning and at the end of the day to ensure she knows the
issues for your patients and their discharge plans.
It would also be helpful if an up-to-date list be kept in the patient care planning
room of which housestaff are looking after which patients so that the
multidisciplinary team knows who to contact if issues arise.
Sign up for clinics with Tracey Cain, divisional secretary on Connell 7, room 706
and also let her know if you are taking any vacation during the rotation.
Ward Rounds you are expected to attend:
Discharge planning rounds: Tuesdays at 12:00
Pharmacy Rounds: Tuesday at 2:00
Expectations of Housestaff
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All housestaff are expected to be punctual for teaching sessions and ready to
begin Thursday morning clinical case rounds at 08:30, if you are presenting. The
projector for the presentation is in Sandy Weatherby’s office C7 Rm 702
Attendance at teaching sessions is mandatory.
Admission or consult Hx and Physicals are expected to be hand written (point
form is acceptable) and include complete history, exam (including systemic AND
neurologic exam), impression with a differential, problem list, and plan.
Daily chart notes for neurology inpatients are expected to be written on each
neurology patient (allowing a reader unfamiliar with the patient to follow the
hospital course easily) and include:
o Brief description of patient
o Subjective statements
o Physical exam including vitals (not VSS)
o Investigation results
o Assessment including Problem list
o Plan (including d/c planning)
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Housestaff on the consultation service are expected to follow-up regularly with
their in-patient consults, write notes if any change in status, and document
investigation results. It is the resident responsibility to inform the senior resident
or Attending of any significant results. In order to derive the maximum benefit
from each patient encounter, you should be reading around all of your cases. Your
senior resident or attending should be able to help direct your reading if needed.
Please ask.
During this rotation, there is scheduled teaching that you will be expected to attend and
participate in (see Educational Rounds below). You also have the opportunity to attend
outpatient neurology clinics. Sign up for clinics with Tracey Cain, the neurology
divisional secretary in room 706, Connell 7 at the beginning of each week. It is expected
that you attend at least 1 clinic per week.
Educational Rounds:
1) Monday: Stroke Rounds: 12:00- 1:00 in the Denis White Library on Connell 7
2) Tuesday: Neuropathology Rounds: 9:00-10:00 in the Pathology Department (Douglas
wing, level 1)
3) Wednesday: Mortality and Morbidity Rounds: 8:00-9:00 in the Richardson
Amphitheatre
4) Thursday
i) Clinical Case Rounds: 8:30-9:30 in Kidd 7 conference room
 the housestaff on the wards or consult service are responsible for presenting at
these rounds (except on the last Thursday of the month when neurosurgery
presents) – talk to the attending neurologist early in the week to decide on topic
for the presentation
ii) Neuroscience Grand Rounds: 9:30-10:30 in Kidd 7 conference room
At the end of this document, a neurology checklist is being provided to you so that you
can record your clinical experience on the ward or on consults. It lists a number of skills
and components of the neurological examination that we hope you learn while on your
rotation as well as neurological symptoms and diseases that are common in neurology.
We hope that you will be exposed to many of these symptoms and diseases and will
develop an approach to the assessment and management of these patients. If there are
areas where you have not had exposure, you can either read about it on your own or ask
the neurology senior or the Attending to provide teaching in that area. We have also
provided an empty chart for you to complete on expected neurological findingss. If you
can complete this chart correctly, you will have a good approach to localizing the lesion
at various levels of the neuro-axis. You can ask one of the Attendings to review this
chart with you during a teaching session.
Evaluations:
1. Mini-PEX or mini-CEX:
 If you require one to be completed, please ask an attending at the beginning of
his/her week (typically of the 3rd or 4th week) so arrangements can be made.
2. Final Evaluation:
 The attending neurologist who is on the service for the last full week of your
rotation will be responsible for doing your evaluation. Please let that
attending know at the beginning of that week that you are finishing and set up
a time for your evaluation. Tell him/her who else you worked with during the
rotation (in clinics or on service) so he/she has time to get feedback from
them.
ROTATION IN NEUROLOGY CHECKLIST
Neuro
History
Neuro
Exam
Cognitive
Localization

Normal CT
Language
Normal MRI
CNs
Signs &
 Symptoms
Muscle Weakness
Diseases

Stroke
Blood Supply
Numbness &
Tingling
Imbalance
Multiple
Sclerosis
Epilepsy
Motor
Stroke
Vertigo
Migraine
Sensory
Intracranial
Hemorrhage
Tumor
Vision Loss
Brain Tumors
Diplopia
Parkinson’s (+)
Gait
Headache
Alzheimer’s
Comatose
Seizures
ALS
Confusion
Myasthenia
Gravis
Common
Neuropathies
Common
Myopathies
Cerebellar
Dementia
Aphasia
Coma
Procedures


Lumbar
Puncture
EMG/NCS
EEG
To make the most of this checklist:
A good neurological history is geared to the neurological complaint.
Examples:
1) If someone presents with a stroke/TIA and has a history of TIAs, it is essential to
find out the symptoms of the TIAs to determine if all coming from the same
vascular territory. It is also necessary to determine their risk factors for having a
stroke including CAD/PVD, DM, hypertension, hypercholesterolemia, afib, neck
trauma (dissection)
2) If someone presents with a seizure, it is important to get a good description of the
seizure from a witness to try and determine if it is focal in onset or generalized. A
good history should elucidate why they had a seizure. For example, perinatal
brain insults, febrile convulsions, CNS infections, head trauma, cancers, strokes,
drugs, alcohol, electrolyte abnormalities etc
3) If someone presents with confusion, you need to determine whether it is
fluctuating as seen with delirium, is progressive suggestive of a
neurodegenerative process, is due to a language problem or psychiatric problem
Neurological examination:
Ensure you are comfortable with various aspects of the neurological examination and
how to interpret abnormalities
Example:
1) Cognitive assessment using MoCA or MMSE
2) Language assessment: naming, repetition, fluency, comprehension, reading and
writing
3) Motor examination usually involves assessing tone (Spasticity, rigidity, paratonia,
hypotonia), bulk (atrophy?) Strength (MRC grading system), reflexes and plantar
response
4) Sensory examination includes large fiber sensory nerves (Vibration and position
sense) or small fiber sensory nerves (pain, temperature, autonomic) and sometime
cortical sensory perception (graphesthesia, stereognosis). Reflexes may be
decreased if large fibers are affected
5) Cerebellar exam includes examination of eyes for nystagmus, speech for scanning
dysarthia, truncal ataxia, limb ataxia, +/- tone (hypotonia), +/- reflexes (pendular)
6) Gait examination: to recognize gait of patients with stroke or other UMN lesion,
parkinson’s, cerebellar ataxia or MSK problems
7) Comatose patient: Understand importance of breathing patterns, papillary
abnormalities, extra-ocular movement abnormalities, and motor responses in
localizing the lesion.
Signs and Symptoms
Start with a wide differential diagnosis and wheedle it down based on questions asked in
your history.
Example: If someone presents with muscle weakness, it could be due to anything from a
myopathy, neuropathy, neuromuscular junction abnormality, spinal root problem, spinal
cord problem or brain problem. Ensure it is not something else such as generalized
fatigue or numbness. Based on answers to questions about location, duration and
progression of weakness, fatiguability as well as associated bowel and bladder
complaints, pain, numbness or tingling or cortical signs (eg aphasia, apraxia,
stereognosia, graphesthesia), you should be able to limit your diagnosis enough to at least
know what investigations to order (Brain or spinal cord imaging or NCS/RNS/EMG)
Diseases:
Stroke ischemic:
1) NIHSS
2) Vascular territories
3) Risk factors
4) Etiology
5) Treatment: indications and contraindications for tPA
6) Secondary Stroke Prevention: carotid endarterectomy, anticoagulation,
antiplatelet, Statins, BP control etc
Hemorrhagic:
1) Possible causes of ICH based on location, timing
2) Treatment
3) Prognosis
Epilepsy/Seizures/Status Epilepticus
1) Classification
2) Etiology
3) Treatment
Migraine
1) Associated symptoms
2) Treatment: acute and prophylaxis
Brain tumor
1) Primary Brain tumors
2) Metastatic brain tumors: tumors that commonly go to the brain
3) Tumors that commonly cause hemorrhage
4) Treatment
Parkinson’s (+)
1) Symptoms
2) Differential diagnosis: progressive supranuclear palsy, multiple system atrophy,
cortical basal ganglionic degeneration, drug-induced
3) Treatment
Alzheimer’s
1) Natural history
2) Differential diagnosis: frontotemporal dementia, lewy body dementia, vascular
dementia
3) Treatment/management
ALS
1) Presentation
2) Diagnosis
3) Management of complications: breathing, swallowing
Myasthenia gravis
1) Symptoms
2) Diagnosis
3) Complications
4) Treatment
Common Neuropathies
1) Approach to neuropathies
2) Causes
3) Treatment
Common Myopathies
1) Approach to myopathies
2) Causes
3) Complications
4) Treatment
Procedures:
References
LP video: http://content.nejm.org/cgi/video/355/13/e12/
Comment: when obtaining opening pressure, it is important for patient to be as relaxed as
possible which should include straightening legs once the needle is in place
EMG/NCS: Know the indications
EEG: know the indications and how to interpret the report
Central
Cortex
Tone
Bulk
Strength
(pattern of
weakness)
Fasciculations
Reflexes
Sensory
Neighbourhood
signs
Peripheral
BG
Cerebellum Spinal cord Nerve root Peripheral
nerve
NMJ
Muscle
Useful Web Sites:
www.uwo.ca/cns CNS department homepage, includes information about
department, teaching schedule, etc.
www.uwo.ca/cns/resident Neurology resident home page, has education topics and
great links to neurology web sites
Neuromuscular information http://www.neuro.wustl.edu/neuromuscular/
Stroke trial information http://www.strokecenter.org/trials/
Baylor neurology case of the month – a case based interactive website
http://www.bcm.edu/neurology/challeng/case_current.html
Useful Reading
Any basic neuro anatomy textbook
Aids to the Examination of the Peripheral Nervous System 4th edition