Neurology Clerkship Orientation

1. Neurology Clerkship Orientation 2012-2013 Rob Naismith M.D.

3. Applying Knowledge and Clinical Skills • Apply Knowledge from DNS to Patient Care. • Read about patient’s differential and condition • Synthesize the case for diagnosis • Use the primary literature for patient management • Learn and Refine Clinical Skills • Obtain patient experience and communicate with family • Collect all the data • Communicate with health care team • Work productively to help team and guide care • Professionalism and Attitude • Enthusiastic about trying to help the patient • Proactive about learning • Contribute to discussion and education

4. Clerkship Components

6. Objectives • Perform a Comprehensive Clinical Assessment • Synthesize the Case for Prioritized & Logical Differential • Summarize the Case and Your Assessment for Oral Presentations and Write-Ups • Develop your Knowledge and Use Literature • Follow and Advocate for your Patients • Work with Team and Increase Independence

7. Symptom-Based Approach THE CHIEF COMPLAINT! • Disorders of consciousness • Mental status and/or behavioral changes • Memory complaints • Pain in the head, neck, and back • Numbness, paresthesias, and neuropathic pain • Weakness and clumsiness • Dizziness and vertigo • Disorders of language • Vision loss and diplopia • Dysarthria and dysphagia • Abnormal movements • Sleep-related complaints

8. Disease Categories • Headaches • Myelopathies • Radiculopathies • Neuropathies • Immunologic Diseases • Movement disorders • Neuromuscular disorders • Brain tumors • Stroke & Hemorrhages • Structural Coma • Metabolic Encephalopathies • Neuro-Toxicology and Vitamin Deficiencies • Meningitis & Encephalitis • Dementia & Memory • Seizures & Syncope • Vertigo Details found on Clerkship Website

9. Required Conferences GOOGLE CALENDAR • Core Clinical Conference • Neurosurgery Lectures (Tues morning) • Localization and Imaging Workshops • Professor’s Rounds • Grand Rounds (Fri morning) • Oral Presentation Skills Workshop (1st Fri) • Neurologic Exam Skills Workshop (1stMon) • Landau Ethics Conference (last Wed afternoon) • LP Simulation Session with Chief Resident (1st Week) You are welcome to attend most other lectures. Speak to your resident. (Resident Report, Summer Stock, Residents as Teachers are just for residents).

10. Conference Aims • Professor’s Rounds • Synthesize the case history, Pro-actively localize, Create a prioritized differential diagnosis, and Build expectations for neuro exam • Sign-up (no Peds Cases, no more than 1 Stroke Case) • Oral Presentation Skills Workshop • Provide clear, concise, and well-organized patient presentations for rounds • Sign-up • Neurologic Exam Skills Workshop • Master the technique and flow for the screening neurologic exam • Localization and Imaging Workshop • Review neuroanatomy, Interpretation imaging studies, and Apply localization for differential diagnosis • LP Simulation Workshop • Consent and perform a lumbar puncture with good technique

11. Inpatient Structure • Two Teams: Stroke and General • One Attending, One Chief, Four Residents • Students belong on a team • Assigned a resident for call • Student on Stroke Call caries tPA pager • Both Teams take call each night • Call typically every 4th • Schedule typically synchronized with assigned resident • Day admissions (Short) through 5pm or cap • Call admissions (Long) typically start at 5pm

12. Overnight Call • Work with resident on New Admits and Sign-Outs • Read about Patients, Prepare Write-Up and Presentation • Students typically get around 2 patients. • Take early patients • Bed on 4th floor • Leave post-call at 1pm if required noon student conference, or 12pm if no noon student conference • Do not go to conference at 1pm or later • If post-call, and you have a new patient presentation in conflict with morning conference: Go to the conference, but let the conference attending know you will need to excuse yourself just prior to the patient presentation

13. Start Day • Pick-up several patients to follow • Review charts for patients on your team • Have patients to present on rounds for Day 2 • Inpatient Adult during the second half of the block begins on the weekend

14. Clinics • Inpatient Adult Service: • Often matched with your assigned resident (adult or peds) • BJC Center Outpatient Care, ConnectCare, Children’s Clinic • Peds Consults • Will pick one ½ day clinic each week, Dr. Larsen to advise • Adult Consults • Pre-scheduled based upon your choices • Neurosurgery • Weekly ½ day resident clinic

15. Patient Logs • Required log of Neurology Symptoms, Diagnoses, and Situations done on New Innovations • Enter 2-3 patients per day • Enter your patients daily • Comment field FYI • Not evaluated • Can enter one thing you learned, brief summary, etc • Do not need to write in full sentences

16. Books • Review Diseases of the Nervous System notes • Pick one - Lange Neurology, Blue Prints, Case Files • Consider supplementing with Pre-Test • Review Disease List on Clerkship Website • Text books, on-line websites, primary literature for patients

17. Evaluations REPORTER INTERPRETER MANAGER • Good knowledge of Neurosciences and Neurology • Can get an essential history and reliable/complete exam • Enthusiastic about new patients and helping team • Shows steady improvement • Very good with patients and families • Presentations are organized and concise with good differential • Hard-working, reliable, cares about getting everything done correctly • No deficiencies Meets Expectations Pass • Apply knowledge toward patient management • Gain independence • Proactive about education • Contributes to rounds and didactics • History geared towards functional impact and differential • Access primary literature for patient questions • PE integrates observations/findings • Patients and families identify them as their doctor • Differentials are honed towards presentation and preliminary testing Exceeds Expectations High Pass • Consistently impacts patient care • Uses neuroanatomy and pathophysiology to make diagnoses • Makes clear ties across HPI, PE, and tests to have concise/complete differential with rationale • Consistently knows more about the patient than anyone else • Takes an interest in all patients on service to learn and help team • Adapts PE to situation and adds additional testing observed on rounds • Able to self identify tasks they can accomplish with good judgment • Advocates for their patient to improve stay Greatly Exceeds Expectations Honors

18. Examples • Teaching topic on the approach to neuropathies • Wheels their patient to cardiac echo when transport doesn’t show so they can go to rehab same day • History includes how the disease impacted ADLs and ambulation • Recognizes Horner’s syndrome and lists lung cancer high in the differential • When asked on rounds, knows that a diabetic 3rd can spare the pupil • Teaching topic reviews evidence and guidelines for using steroids and acyclovir for patient with Bells Palsy • Differential for headache complete, but includes some extremely unlikely considerations • Patient presentation summarizes exam findings as normal but notes specific negative findings based upon differential • Returns to see patients after clinic to review the chart, find out about developments, and update them on progress • Asks resident “What can I do to help?” • After holiday break, emails resident and asks which patients they should pick-up before rounds on their day back.

19. Feedback and Evaluation Reporter – Interpreter - Manager • Objective • Criterion based • No curves of cutoffs • Emphasizes level of thought process and ability to adapt • Individual • You are not compared to one another • Teamwork among students is positive • High Expectations • A Reporter is someone I could recommend to a residency or feel comfortable having them care for my family • We Want You To Do Well • Feedback so you know where you stand • Detailed comments • Dr. Larsen’s Experiential Learning Project • “Greatly Exceeds Expectations” is a success for us all

20. Welcome to Make Appointment • Come if you have questions, requests, or concerns. ANY QUESTIONS