Educational Objectives WSU – BSOM Neurology Clerkship

I. Knowledge and Life-Long Learning

By the end of the clerkship, the student will demonstrate the ability to:

• Organize clinical data from patient interviews and neurological exams to hypothesize lesion localization and neurologic diagnoses
• Develop thorough neurologic differential diagnoses based upon patient data
• Perform and document a neurologic examination including a
  -Comprehensive neurologic exam (Appendix 1)
  -Screening neurologic exam (Appendix 2)
  -Neurologic examination in patients with altered level of consciousness (Appendix 3)
• Recognize and interpret abnormal findings on a neurological exam

By the end of the clerkship the student will be able to recognize the general principals governing:

• Localization -Understand the general principles differentiating lesions at the following levels
  -Cerebral hemisphere
  -Posterior fossa
  -Spinal cord
  -Nerve root/Plexus
  -Peripheral nerve (mononeuropathy, polyneuropathy, and mononeuropathy multiplex)
  -Neuromuscular junction
  -Muscle
• Approach Symptom Complexes – a systematic approach to the evaluation and differential diagnosis of patients who present with:
  -Focal weakness
  -Diffuse weakness
  -Clumsiness
  -Involuntary movements
  -Gait disturbance
  -Urinary or fecal incontinence
  -Dizziness
  -Vision loss
  -Diplopia
  -Dysarthria
  -Dysphagia
  -Acute mental status changes
  -Dementia
  -Aphasia
  -Headache
  -Focal pain
  -Facial pain
  -Neck pain
  -Low back pain
  -Neuropathic pain
  -Numbness or paresthesias
  -Transient or episodic focal symptoms
  -Transient or episodic alteration of consciousness
  -Sleep disorders
  -Developmental disorders
• Approach to Specific Diseases- the evaluation and management of the following neurologic illnesses (either because they are important prototypes, or because they are potentially lifethreatening):
  - Potential emergencies
  • Increased intracranial pressure
  • Toxic-metabolic encephalopathy and acute mental status change
  • Subarachnoid hemorrhage
  • Meningitis/Encephalitis
  • Status epilepticus
  • Acute stroke (ischemic or hemorrhagic)
  • Spinal cord or cauda equina compression
  • Head Trauma
  • Acute respiratory distress due to neuromuscular disease (e.g., myasthenic crisis or acute inflammatory demyelinating polyradiculoneuropathy, a.k.a Guillain-Barre Syndrome )
  • Temporal arteritis
  • Neuroleptic malignant syndrome
  -Amyotrophic Lateral Sclerosis
  -Brain Death
  -Primary and metastatic CNS tumors
  -Coma
  -Dementia (notably Alzheimer’s Disease)
  -Seizures
  -Multiple Sclerosis
  -Myasthenia Gravis
  -Migraine
  -Movement disorders (notably Parkinson’s Disease, essential tremor, tardive dyskinesia)
  -Myopathies (notably polymyositis) and Muscular Dystrophies
  -Cranial Neuropathies (notably Bell’s Palsy and third nerve palsy)
  -Peripheral Neuropathies
  *Acute (e.g. Guillain-Barre Syndrome)
  *Chronic (e.g. diabetic polyneuropathy, carpal tunnel syndrome)

Note: To some extent, the above sections regarding the exam, localization, symptom complexes and specific diseases represent alternative ways of organizing the same subject matter. Some instructors may choose to emphasize some of these approaches more than others. No matter how the clerkship and educational materials are organized, however, all of the topics included in the sections above should be covered in some way.

By the end of the clerkship, the student will be able to recognize the indication for and basic interpretation of ancillary studies including:
-serological studies
-electrophysiological testing
-neuroimaging studies
-neuropsychological testing
-cerebrospinal fluid testing

By the end of the clerkship the student will be able to recognize psychosocial and quality of life issues related to long-term neurological disability.

II. Interpersonal and Communication

By the end of the clerkship, the student will demonstrate the ability to conduct a neurological interview including:

• establish rapport with patients by properly introducing self and defining the role the interview will have in patients' care
• be empathic with patients, showing genuine concern for patients' dilemmas, and viewpoints;
• demonstrate awareness and sensitivity to any gender/cultural/ethnic issues that may impact evaluation and care
• facilitate interviews with helpful blends of open and closed questions, supportive remarks, uses of silences, and therapeutic interruptions
• conclude interviews with proper timing and respect

III. Professionalism

The student will demonstrate professionalism through the ability to:

• be punctual and attend required events
• complete patient notes in a timely fashion with legible writing
• maintain professional boundaries (physical, sexual, financial, and emotional) with patients
• be truthful about medical data
• be courteous to patients, patients' families, staff, colleagues, and other health professionals
• maintain confidentiality regarding patient care
• demonstrate respect, empathy, responsiveness, and concern regardless of the patient's problems, personal characteristics, or cultural background
• demonstrate sensitivity to medical student-patient similarities and differences in gender, ethnic background, sexual orientation, socioeconomic status, educational level, political views, and personality traits.
• demonstrate integrity, responsibility and accountability in the care of assigned patients
• demonstrate scholarship in the form of contributing to a positive learning environment, collaborating with colleagues, and performing self-assessment and self-directed learning to assess one's strengths, weaknesses and health (physical and emotional), and be willing to seek and accept supervision and constructive feedback

Appendix 1: Guidelines for a Comprehensive Neurologic Exam

• Basic Mental Status
  -Level of alertness
  -Language function (fluency, comprehension, repetition, naming and reading)
  -Memory (short-term and long-term)
  -Calculation
  -Visuospatial processing
  -Abstract reasoning
• Cranial Nerves:
  -Vision (visual fields to confrontation, visual acuity, and funduscopic examination)
  -Pupillary reflexes (light, accommodation)
  -Eye movements (including observation for nystagmus)
  -Facial sensation
  -Facial strength (muscles of facial expression and muscles of mastication)
  -Hearing
  -Palatal movement
  -Speech (observation for dysarthria)
  -Head rotation, shoulder elevation
  -Tongue movement
• Motor function
  -Pronator drift
  -Tone (resistance to passive manipulation)
  -Bulk
  -Strength of major muscle groups
  • shoulder abduction, elbow flexion/extension, wrist flexion/extension, finger flexion/extension/abduction, hip flexion/extension, knee flexion/extension, ankle dorsiflexion/plantar flexion
• Sensation
  -Pain, temperature
  -Light touch,
  -Proprioception
  -Vibration
  -Cortical modalities such as graphesthesia and neglect
• Reflexes
  -Deep tendon (biceps, triceps, brachioradialis, patellar, achilles)
  -Plantar responses
• Cerebellar and complex motor function including
  -Finger-to-nose
  -Heel-to-shin
  -Tremor
  -Rapid alternating movements
  -Fine finger movements
• Gait
  -Casual (base, stride, armswing)
  -Heel walk
  -Toe walk
  -Tandem walk
  -Turn

Appendix 2: Guidelines for a Screening Neurologic Examination

All medical students should be able to perform a brief, screening neurologic examination that is sufficient to detect significant neurologic disease even in patients with no neurologic complaints. Although the exact format of such a screening examination may vary, it should contain at least some assessment of mental status, cranial nerves, gait, coordination, strength, reflexes, and sensation. One example of a screening examination is given here.

A. Mental Status (level of alertness, appropriateness of responses, orientation to date and place)

B. Cranial Nerves
1.Visual acuity
2. Pupillary light reflex
3. Eye movements
4. Hearing
5. Facial strength (smile, eye closure)

C. Motor Function
1. Gait (casual, tandem)
2. Coordination (fine finger movements, finger-to-nose)
3. Strength (shoulder abduction, elbow extension, wrist extension, finger abduction, hip flexion, knee flexion, ankle dorsiflexion)

D. Reflexes
1. Deep tendon reflexes (biceps, patellar, Achilles)
2. Plantar responses

E. Sensation (one modality at toes – can be light touch, pain/temperature, or proprioception)

Note: If there is reason to suspect neurologic disease based on the patient’s history or the results of any components of the screening examination, a more complete neurologic examination may be necessary.

Appendix 3: Guidelines for the Neurologic Examination in Patients with Altered Level of Consciousness

A. Mental Status

1. Level of arousal
2. Response to auditory stimuli (including voice)
3. Response to visual stimuli
4. Response to noxious stimuli (applied centrally and to each limb individually)

B. Cranial Nerves

1. Response to visual threat
2. Pupillary light reflex
3. Oculocephalic (doll’s eyes) reflex
4. Vestibulo-ocular (cold caloric) reflex
5. Corneal reflex
6. Gag reflex

C. Motor Function

1. Voluntary movements
2. Reflex withdrawal
3. Spontaneous, involuntary movements
4. Tone (resistance to passive manipulation)

D. Reflexes

1. Deep tendon reflexes
2. Plantar responses

E. Sensation (to noxious stimuli)

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