Neurology Eval

Faculty Chair:

Leandrita Ortega, MD

Contacts:

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Required Experiences:

Gerald Champion Regional Medical Center

Optional Experience:

Elective rotations

Weekly Schedule PGY3:

Sunday	Monday	Tuesday	Wed	Thursday	Friday	Saturday
	Clinic	Neuro	Neuro	Clinic	Neuro
	Clinic	Neuro	Didactics	Clinic

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Requirements:

AOA

Internal Medicine

The program must provide at least thirty-two weeks of clinical training in internal medicine disciplines, including at least eight weeks of general internal medicine experiences during the OGME-1 year. This requirement can be met by either inpatient internal medicine or inpatient family medicine service.

At a minimum internal medicine training must include:

• Twenty-four weeks of inpatient experience.
• Four weeks of training in critical care medicine.
• Didactic and clinical training.

Internal medicine training shall include exposure to the following disciplines, in either inpatient or outpatient settings:

• Allergy and immunology.
• Cardiology.
• Dermatology.
• Endocrinology.
• Gastroenterology.
• Hematology.
• Infectious diseases.
• Nephrology.
• Neurology.
• Oncology.
• Pulmonology.
• Rheumatology.

ACGME

There must be specific subspecialty curricula to address the breadth of patients seen in family medicine. (Core)

The program must ensure that every resident has exposure to a variety of medical and surgical subspecialties throughout the educational program. (Detail)

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Description of Rotation or Educational Experience:

A solid understanding of normal neurological development, anatomy and neurophysiology is imperative to the treatment of neurological pathology. The goal of this rotation is to sensitize the family medicine resident to the role of neurological disease in patients and familiarize residents with its particular place in the overall practice of family medicine. Neurological problems are estimated to comprise 10 to 15 percent of a family physician’s workload. The specialty of family medicine is vitally interested in all aspects of neurological disease. History-taking in neurology and performance of a comprehensive neurological examination are essential skills for all family physicians. Emphasis on good diagnostic and therapeutic skills and the appropriate consideration of bio-psychosocial and cultural factors must be included in assessment of the neurologic patient.

Expectations:

Residents

Residents are expected to arrive to neurology and continuity clinics on time and to dress and act in a professional manner. They are expected to contact the neurology preceptors’ office prior to their first day on the rotation in order to arrange the initial meeting time and location of the rotation. It is expected that while at the preceptors’ office the residents will be respectful of the office space and personnel. The resident is responsible for maintaining a procedure log as well as completing assigned readings.

Faculty:

Family medicine faculty will provide precepting of neurologic cases and procedures as seen in resident continuity clinics. Dr. Iqbal, and possibly other physicians in his practice, will provide precepting during the focused Neurology rotation. The faculty and preceptors are expected to allow the resident to participate in active patient care and procedures when appropriate. The preceptors should also provide time and allowance for explanation and teaching of neurologic conditions and their treatments.

Call:

There is no call specific to this rotation.

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Patient Care

Goal

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

Competencies

• Be able to perform standardized comprehensive neurological assessments, obtain necessary further investigation and develop acute and long-term comprehensive treatment plans based on the basis of presenting and progressively deteriorating neurological processes.

Objectives

In the appropriate setting, the resident should demonstrate the ability to independently

perform or appropriately refer:

• 1. Evaluation skills
  • Recognizing and defining the neurological problem
  • To be able to take an appropriate focused and comprehensive history (including necessary information from others) and communicate this verbally or in writing and in summary form
  • To be able to examine the mental and physical state (including a complete neurological and mental status examination, Glasgow coma scale and pediatric developmental exam) and communicate verbally or in writing and in summary form to other providers
  • Using clinical knowledge to localize the lesion and formulate an ordered differential diagnosis based on an appreciation of the patient, his or her past history, current problems and likely causes
  • Assessing the acuity and prognosis of the clinical problem as it relates to the need for immediate management and the requirement for expert assistance
  • Formulating a rational plan for further investigation and management
  • Knowing the indications, contraindications, risks and significance of ancillary tests
    • Lumbar puncture and its performance
    • Electroencephalogram
    • Visual, brain stem auditory and somatosensory evoked potential
    • Nerve conduction study and electromyography (NeuralScan)
    • Muscle and nerve biopsy
    • Computed axial tomography with and without contrast
    • Magnetic resonance imaging with and without contrast
    • Magnetic resonance angiography
    • Angiography
    • Myelography
    • Carotid ultrasound
    • Sleep study
    • Genetic testing
    • Positron emission tomography (PET) scanning
    • Single-photon emission computed tomography (SPECT) scanning

• 2. Management skills
  • Formulating a diagnostic and management plan and assessing the need for expert advice with an awareness of the risks, benefits and costs of evaluation
  • Understanding the role of a neurology specialist and the implications of special testing in patients who have neurologic disease and the implications of the test results for the patient
  • Managing the prevalent and treatable conditions listed in this curriculum with consultation as appropriate
  • Managing emergent neurology problems and obtaining urgent consultation when appropriate, including:
    • Stroke
    • Coma
    • Meningitis and encephalitis
    • Status epilepticus
    • Central nervous system trauma
    • Increased intracranial pressure
    • Acute visual loss
    • Rapidly progressive neurological deficit
    • Neurological respiratory failure
    • Acute weakness
    • Altered mental status

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Medical Knowledge

Goal

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:

Competencies

• Be able to understand normal neurological development, anatomy and physiology.

Objectives

In the appropriate setting, the resident should demonstrate the ability to apply

knowledge of:

• 1. Normal anatomy, physiology and anatomic principles that allow localization of neurological disease
• 2. Normal growth, development and senescence of the nervous system
• 3. Pathologic neurological disorders, including:
  • a. Disorders of motor function
    • i. Upper and lower motor neuron disorders
    • ii. Coordination
    • iii. Movement disorders
      • 1). Hypokinetic
        • a). Parkinson’s disease
        • b). Parkinson plus syndrome
      • 2). Hyperkinetic
        • a). Athetosis
        • b). Chorea
        • c). Dystonia
        • d). Tics
        • e). Tremors
  • b. Disorders of sensation
    • i. Central
    • ii. Peripheral
  • c. Disorders of vision
    • i. Visual field defects
    • ii. Monocular and binocular blindness
    • iii. Diplopia and gaze palsies
    • iv. Nystagmus
    • v. Pupillary abnormalities
  • d. Cerebrovascular diseases
    • i. Ischemic stroke
      • 1). Thrombolytics
        • a). Indications and use
        • b). Risks and benefits
    • ii. Hemorrhagic stroke
    • iii. Vasculitis
    • iv. Transient ischemic attacks
    • v. Symptomatic and asymptomatic carotid stenosis
    • vi. Aneurysmal disease
  • e. Head and spinal cord trauma
    • i. Evaluation
    • ii. Management to include long-term complications
    • iii. Consequences and prevention
  • f. Multiple sclerosis
    • i. Diagnostic criteria
    • ii. Laboratory findings
    • iii. Management
  • g. Dizziness and disorders of hearing
    • i. Central vs. peripheral hearing loss
      • 1). Acute
      • 2). Chronic
    • ii. Central vs. peripheral vertigo
      • 1). Acute
      • 2). Chronic
      • 3). Evocative testing (e.g., Dix-Hallpike maneuver)
    • iii. Tinnitus
  • h. Disorders of higher cognitive function and communication
    • i. Dementia
      • 1). Differential diagnosis
      • 2). Evaluation
      • 3). Management
    • ii. Encephalopathy (acute, chronic)
      • 1). Toxic
      • 2). Metabolic
    • iii. Aphasia and apraxia
  • i. Disorders of consciousness
    • i. Syncope
    • ii. Epilepsy
      • 1). Generalized at onset seizures
      • 2). Simple partial seizures
      • 3). Complex partial seizures
      • 4). Treatment
        • a). Medical management with anticonvulsant medications
        • b). Surgical management
        • c). Vagal nerve stimulation
    • iii. Recognition and treatment of increased intracranial pressure
    • iv. Stupor and coma
      • 1). Toxic and metabolic
      • 2). Structural disease
      • 3). Herniation syndromes
    • v. Brain death
  • j. Headache
    • i. Migraine and variants
    • ii. Cluster headache
    • iii. Tension-type headache
    • iv. Headache associated with a structural lesion
    • v. Benign intracranial hypertension (pseudotumor cerebri)
    • vi. Chronic daily headache
    • vii. Emergent headaches
      • 1). Subarachnoid hemorrhage
      • 2). Meningitis
      • 3). Giant cell arteritis and temporal arteritis
  • k. Brain tumors
    • i. Anterior or posterior fossa
      • 1). Primary
        • a). Benign
        • b). Malignant
      • 2). Metastatic
  • l. Infections (e.g., meningitis, encephalitis)
    • i. Bacterial
    • ii. Viral or retroviral (human immunodeficiency virus)
    • iii. Fungal
    • iv. Tuberculosis
    • v. Prion disease
    • vi. Parasitic (especially cystercicosis)
  • m. Spinal cord disorders
    • i. Anatomy and localization
    • ii. Extrinsic compressive lesions
    • iii. Intrinsic lesions
  • n. Sleep disorders (e.g. central and peripheral sleep apnea, periodic limb movement disorder)
  • o. Disorders of peripheral nerve, neuromuscular junction and muscle
    • i. Muscular dystrophy
    • ii. Peripheral neuropathy
    • iii. Mononeuritis multiplex
    • iv. Myopathy
    • v. Guillain-Barre syndrome
    • vi. Myasthenia gravis
    • vii. Plexopathy
    • viii. Radiculopathy
    • ix. Diagnostic studies (e.g., nerve conduction velocity, electromyograph, neural scan, muscle biopsy)
  • p. Congenital disorders
    • i. Brain and spinal cord malformations
      • 1). Arnold-Chiari malformation
      • 2). Meningomyelocele
      • 3). Cortical malformations
  • q. Chromosomal abnormalities (e.g., Down’s syndrome)
  • r. Abnormal head growth
    • i. Microcephaly
    • ii. Macrocephaly (including hydrocephalus)
  • s. Aberrant development
    • i. Development delay
    • ii. Mental retardation
    • iii. Neurodegenerative diseases
  • t. Developmental disorders of higher cerebral function
    • i. Mental retardation
    • ii. Developmental language disorders
    • iii. Learning disabilities (e.g., dyslexia)
    • iv. Attention deficit disorder, with or without hyperactivity
    • v. Pervasive developmental disorders (e.g., autism)
  • u. Psychiatric disorders mimicking neurological disease
    • i. Non-epileptic spells (e.g., pseudoseizures)
    • ii. Dementia of depression (e.g., pseudodementia)
    • iii. Conversion disorder
    • iv. Malingering
    • v. Disorders of somatization and hypochondriasis
• 4. Principles of pain management
  • a. Pharmacologic agents
  • b. Surgical management
  • c. Cognitive and behavioral techniques
  • d. Interventions such as injections, nerve stimulation and nerve root ablation
• 5. The psychological and rehabilitation aspects of patient management, especially for chronic or long-term neurological conditions. The use of other specialties including physical/manipulation, massage, occupational therapy and integrative medicine adjuncts to patient management
• 6. The genetic basis of certain neurological disorders as they affect the patient, his orher family and education of the family regarding the benefits of genetic counseling
• 7. An understanding of the neurological disabilities of elderly patients and the importance of assessing, restoring and maintaining their functional capacity (see also the Curriculum Guidelines for Care of Older Adults)
• 8. Neurological complications of systemic illness especially zoonotic diseases (such as cystercicosis) that affect the nervous system
• 9. Prevention of neurological disease
• 10. Special Situations
  • a. Understand the effect of pregnancy on existing neurological disorders and neurological disorders as complications of pregnancy
  • b. Understand the special needs of an adolescent patient’s issues of confidentiality and transition disorders
• 11. Geriatric Issues
  • a. Understand the normal clinical and radiological findings in the elderly
  • b. Understand the special presentations of neurological disease in the elderly diagnosis, investigation and management of dementia
  • c. Understand the effects of drugs in the elderly
  • d. Understand the hospital-based and community services for the elderly
  • e. Understand how to communicate with relatives and care agencies for the elderly and the importance of assessing, restoring and maintaining their functional capacity (see also Curriculum Guideline for Care of Older Adults –AAFP Reprint No. 264 – http://www.aafp.org/cg.
• 12. Understand end-of-life issues in neurological disorders, the role of palliative care services and ethical and legal aspects of terminal care.

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Practice Based Learning and Improvement

Goal

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to:

Competencies

• Be able to recognize his or her own practice limitations and seek consultation with other health care providers to provide optimal care.

Objectives

• Complete assigned reading topics and apply learned material in the clinical setting
• Demonstrate ability to identify limitations in own knowledge and take steps to fill these gaps.

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System Based Practice

Goal

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

Competencies

• Be able to optimize treatment plans based on knowledge of local resources that include local, state and federal agencies.
• Coordinate ambulatory, in-patient and institutional care across health care providers, institutions and governmental agencies.

Objectives

• Make appropriate referrals to and coordinate care with neurologists for those conditions that fall out of the scope of family medicine or do not respond to that treatment which family physicians can provide
• Demonstrate cost effective care and diagnostic testing

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Professionalism

Goal

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

Competencies

The list below reflects competencies that fall under Professionalism. Which of the following competencies are relevant for the rotation or educational experience you have chosen? (Pick one or two)

• Compassion, integrity, and respect for others
• Responsiveness to patient needs that supersedes self-interest
• Respect for patient privacy and autonomy

Objectives

• Display sensitivity for patient privacy and autonomy during exams and procedures
• Engage in interviewing techniques which demonstrate cultural and social sensitivity

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Interpersonal and Communication Skills

Goal

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:

Competencies

The list below reflects competencies that fall under Interpersonal and Communication Skills. Which of the following competencies are relevant for the rotation or educational experience you have chosen? (Pick one or two)

• Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
• Act in a consultative role to other physicians and health professionals

Objectives

Communicate with patients and their families in a respectful, and concise manner that facilitates understanding with minimal jargon.

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Teaching Methods

Residents will provide medical care to patients under the direct supervision of the attending physician. They will be supervised on all procedures performed. They will participate in weekly conferences. Residents will be assigned specific reading topics to be completed by the end of their month on the service.

Assessment Method (residents)

Direct observation with a ongoing global assessment based on the REDI system. All procedures will be recorded on New Innovations and independence for each procedure assessed using the REDI system. Evaluation from each of the community preceptors to be completed at the end of the rotation. Review of documentation by family medicine preceptors as part of continuity clinic supervision.

Assessment Method (Program Evaluation)

Residents will be provided with an evaluation of their experiences and given the opportunity to provide feedback of the rotation during their quarterly IEP assessments.

Level of Supervision

The resident is directly supervised by the attending physician during all procedures performed. An Attending will be available the entire time the resident is on the rotation. An Attending will be available at all times during continuity clinic visits.

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Educational Resources

Readings

Week 1

Week 2

Week 3

Week 4

Text Books

Cooper JR, Bloom FE, Roth RH. The Biochemical Basis of Neuropharmacology. 8th ed. Oxford, N.Y.: Oxford University Press, 2003.