Neurology

Report
Neurology Tips and Tricks
INTRO TO CLINICS NIGHT
From your Upper Classmen Friends
It all became worth it when…
“...When I could sit and listen to an elderly man with severe dementia and
depression for as long as he needed to talk
“...When a chronic neuropathic pain patient was so touched by the fact
that I held her hand during a procedure that she asked the nurse to tell
my resident to call me after I had left the rotation just to thank me.”
“...When I could help an older gentleman come up with smoking
cessation strategies after he suffered a minor stroke.”
Staying Sane
 Don’t let your empathy get fatigued! Taking
an extra moment to listen to your patient is
a good way to improve patient care, help
your team, and make the experience more
fulfilling for you!
Day 1: Service Assignment
 First day you meet with Amy Pruitt, and she
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will assign you to a service by your interests
“I have no idea what I want to do” =
Consults
“I’m thinking medicine” = Stroke or General
Ward
“I’m thinking Peds” = Pediatric consult
service
“I’m interested in primary care or
outpatient medicine” = Presby rotation
What’s the difference
 Personal opinion
 Do not say Peds unless you are 100% sure. If you
are DEFINITELY going Peds, it will be helpful to do
seizure consult, seizure consult… But this doesn’t
generally offer the breadth of what’s on the shelf
 Dr Khella at Presby is an amazing teacher, but this is
a very fast paced ambulatory rotation where you
may feel overwhelmed if it’s your first rotation
 General neurology, consults, and stroke all offer a
good variety; the ward services function much like
medicine services
What should I buy/borrow?
 Books
 Blueprints – High yield and a good, broad
overview
 Case Files – In-depth cases that make you think
about what’s going on (my personal favorite).
 The Yellow Pages – Dr. Pruitt will give them to you
on the first day. Use these last as a review.
 USMLEWORLD!!! – do the neurology questions.
SUPER high yield. Crucial, even
What should I buy/borrow
 Supplies
 Get tongue depressors from the supply closet on the floor or
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when you start consults, you can break them in half (so they’re
jagged) and use them to test “pain”
Alcohol swabs (also in every ward’s supply closet) test “cold”
Pin light
Reflex hammer (the dinky triangle ones suck and are hard to
get reflexes with,… but they are the cheapest)
Tuning fork
Having something Red is helpful for testing color vision
Ask a resident if you can borrow their Panoptic
…. Or you can use an ophthamoscope… if you figure out how to
see the optic disk with this reliably, let me know, because I sure
can’t (DO NOT lose the panoptic though… its $700 and your
resident will be unhappy)
Also helpful
 Maxwell cards have a section on mental status
(purple page) – YOU SHOULD ALWAYS TEST in
Neuro patients
 In every other rotation it’s ok to say “alert and
oriented” but for neuro you need to be more specific
 A visual acuity card. Sometimes asking the
patient to count fingers in the four quadrants
of their visual field (while they look at your
nose) is enough… sometimes you need to be
formal
 Micromedex or another drug app can be very
helpful
Tips and Tricks: Homepage
Tips and Tricks: Sunrise
Tips and Tricks Sunrise
How to be in the know!
The Neuro Exam
 Mental status
 Time? (Year, season, month, day, date)
 Location? (State, county, town, hospital, floor)
 Ask the patient to repeat 3 objects and to remember
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them Serial 7’s or spell WORLD backwards
Ask for the 3 objects named above
Point to 2 objects and have the patient name them
Repeat “No ifs, ands, or buts”
Follow command: “Take the paper in your right hand,fold
it in half and put it on the floor.”
Read and obey the following written words: “CLOSE
YOUR EYES”
Write a sentence
Copy a design
The Neuro Exam, Con’t
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Cranial Nerves
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II: Optic: Can use the eye chart in Maxwell’s; Remember to do visual fields
III/IV/VI: Extraocular movement; light reflexes
V: Trigeminal: You can do a variety of things, (corneal reflex, jaw opening,
bitestrength), but most just test facial sensation
VII: Facial: eyebrow raise, eyelid close, smile, frown, pucker, taste
VIII: Vestibulocochlear: Hearing; Rinne, Weber, doll’s eye,
IX,X: Glossopharyngeal, Vagus: gag reflex, swallowing, palate elevation
XI: Spinal Accessory: lateral head rotation, neck flexion, shoulder shrug
XII: Hypoglossal: Tongue protrusion
Motor
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5/5: full strength
4+/5: you can break them if you push really hard
4/5: Offer some resistance
3/5: Can hold their arms/legs up against gravity, but are easily pushed down
2/5: Can move minimally but cannot hold extremities up
1/5: flicker of muscle movement
Give-way weakness: you get the sense that the patient probably has full
strength, but isn’t trying very hard
The Neuro Exam, Con’t
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Sensation
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Reflexes
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0 = no reflex at all
1(+) = you get a small jerk
2+ = normal
3+ = brisk, “jumpy” (can be normal in young people, if they are SYMMETRIC, asymmetric
reflexes should make you pause)
4+ = non-sustained clonus (repetitive vibratory sensation you feel)
5+ = sustained clonus (rarely seen)
other signs of hyperreflexia include spreading of reflexes to other muscles not directly
being tested and crossed adduction of the opposite leg when the medial aspect of the knee
is tapped
Coordination
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Cold: alcohol swab
Pin-prick: broken tongue depressor
Proprioception: without looking, am I moving your big toe up or down?
Vibration: tuning fork
Light touch: you touch their skin
Finger-nose-finger, rapid alternating movement, heel to shin
Gait (test in everyone able to walk): tandem, heel walking, toe walking
Where to find Neuro Exam form:
Click “Housestaff Portal – Pulse” on Right side of the MedView Homepage 
Click Neurology on the Left side of the Screen  click “common forms”
Handling a New Admission/ ED consult
 Go to Medview  Look up ED admission
 Can see the ED’s H&P (will usually not include a neuro exam)
and their initial impressions / workup that’s been done
Look and see if there are any lab abnormalities… for example a K of
2.6 may explain the patients altered mental status and take some of
the “neuro” off the differential.
 Patients with a history of thromboembolic stroke are often
anticoagulated, look at their PT if on Warfarin…
 If they’ve had any imaging, take a look, it’s nice to look at the images
themselves, but you can also definitely use the radiology reads
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 Go see the patient vs. look on uptodate.com if you want to
know the DDx for something so that you can tailor your
questions appropriately
 Do a FULL Neuro Exam. If you miss something… go back… it’s
worth looking awkward to the patient, you’ll get better about
being more complete as the year goes on!
Notes on Consults
 In the ICUs: check the paper chart first, the ICUs generally
generate a daily progress note that is quite
comprehensive and will give you a mostly-complete
picture of the patient to that point.
 Comatose patients: scary at first – ask your resident if
you can go together for the first one.
 Check pupils (II), corneals (with saline drops) (V, VII), dolls
eyes (VIII), Gag (IX, X)
 Motor: use your reflex hammer to press (hard) on their
nailbeds (it seems cruel, but this really helps you understand
the patients’ overall state)
 Localizing: patient pulls away
 Extensor
 Flexor
 Test all reflexes, including babinski
Presenting
 Be methodical and thorough with history & exam
 In order, same way every time, go back if needed
 At least at the beginning, write it out (Type!)
 Know everything, but only say what you actually
think is important.
 In the beginning, all parts of the Neuro Exam are
important, don’t forget the mental status
(attendings will call you out if you didn’t test
language… it’s a neuro thing…:/)
 Be prepared to answer other questions
 Know the normal values for any labs you state
 Follow-Up Presentations: SOAP
SOAP Notes
 Subjective - Report on any overnight events
and how pt is feeling (ask about f/c, n/v,
SOB, CP, abd pain, constipation, and
diarrhea.
 Objective - Report VS (Tm, Tc, HR, BP, R,
SaO2, weight), NEURO EXAM
 Assessment - Summary statement.
 Plan - plan for pt, often in order of
importance of problem, by problem or by
organ system.
Topic Presentations
 Start with a summary source: UpToDate,
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Neurology (Journal),
Be focused --> brevity is the soul of wit here
more than ever
Make a handout, but say more than is on
the handout
Incorporate actual evidence (use UpToDate
or review
End strong: Zinger, 3 take-away points
Useful Shorthand
Imaging
Support Systems
Suite 100:
- JoMo, Barb, Helene
- Tutors set up through suite 100
Organized counseling:
- CAPS: http://www.vpul.upenn.edu/caps/
- Therapists in the community (Barb from Student Affairs can provide names
and contact info)
- Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentors
Other people to turn to:
- Doctoring preceptors
- Advisory deans
- Clerkship directors (it’s really ok to talk to them!)
- Mentors you have connected with in pre-clinical years (through clinics,
volunteering, etc)
- Friends and family outside of medicine
Supplemental Stuff
 UpToDate from Home
 Access the hospital's Extranet at
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https://extranet.uphs.upenn.edu/
Use your MedView username / password to log in
Create a bookmark on your home page for UpToDate
Click on the "+" that's on the far right side of the "Web
Bookmarks" heading
Name your bookmark and put this URL in the URL spot:
http://uphsxnet.uphs.upenn.edu/uptodate
Click on new bookmark that's now on your home page
Use UpToDate like you would from on campus
HUP OR Schedule:
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Homepage: Left hand side, click on Departments-->Perioperative
Services-->OR Schedule. The user name and password are both hupor
Supplemental Stuff
 Bug Drug: UPHS guidelines for anti-
microbial therapy
 Pulse:
 Phonebooks for each hospital
 #s for Consult services
 Lots of assorted resources, guidelines, forms
 Phone #s to store in your cell
 Hospital operator
 General lab

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