How to do well on the Neurology Clerkship (not just the Shelf)?

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Jun 13, 2011
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Hi everyone!

I was wondering how to do well on the Neurology clerkship-- not just resources for preparing for the shelf. Due to a different curriculum, I haven't done a physical exam in about 3-4 months. Yikes.

1) Do you recommend having a pocket book to refer to? If so, which one (MGH, Rapid response etc.) Do you actually have time to refer to these books and are they useful? Or would any down time that you have to refer to these books be better invested in doing UWorld questions for the shelf?

2) What resources did you use to learn how to perform a concise and precise neuro exam? (It's been a while lol...)

3) What sorts of things do the residents expect you to be able to do? Some people have said lumbar punctures, which I've never done!


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yikes no one expects you to know how to do a lumbar puncture!

there is more than one way to test in neuro, so a good idea is to watch whoever you are working with closely and emulate their exam, however, you want to be sure you don't skip anything as they might do

Do you have Bate's guide to physical examination? If you want to shine in neuro than you need to not pull any punches when it comes to physical exam

pocket med books are not likely to help you
Maxwell's Pocket Guide I think is great overall, and you can use the neuro section as a cheat sheet
Has the entire exam, mental status exam, dermatome map, nerve-roots, etc
NIH Stroke Scale towards the start

definitely have a system for you to work through top to bottom
my order might not work for you
the best thing is to get a system of how to do it all, then practice on some classmates until you have it memorized and can do it with reasonable speed
believe me, if you have that down day 1 everything will be faster and you will look good

I would usually start with cranial nerves going in order so I wouldn't forget any of them (skip 1 unless you have the little neurologist sniff cards or feel like carrying coffee beans with you, test one nostril at a time if you do)
Maxwell's also has an eyechart for acuity (don't forget to do this especially eye complaints)
Some skip acuity but definitely make sure visual fields are intact to finger counting (some might just do confrontation but that's sloppy)
(when you start do acuity until you are told you don't have to)
If you have Bate's Guide to Phys Exam brush up on your opthalmoscope skills - bonus points if you can figure out how to at least see the disc by the time you start, in fact most of Chapter 7 Head and Neck will help you (I don't care if you can see it or not, every patient you at least need to pick up the opthalmoscope and try to find the disc or you will look like total ****)
When you check eye movements, don't be lazy really move that finger, many subtle abnormalities with muscles are only seen at the upper limit of range, many will do it once slowly allowing the eyes to remain at limit of range for a few moments and again fast, to look for quick or slow components to nystagmus, to to this I end up doing the H and the X
If one pupil is different in size than the other, *always* ask if they had this before, when it was first dx'd or what have you (up to 38% of folks have anisocoria and funny how you won't notice this until you're doing a neuro exam. Clearly document on a patient's chart if they do have it, measure it, and document best you can if it was an incidental finding or if there is a cause what the cause its. It can save headache later down the road)
Don't forget that to test V Trigeminal you need to not only test the sensory branch by touching the face in 3 zones but also by having them bite down while you are palpating the temporal and masseter muscles on both sides (almost a Vulcan mind meld grip but 2 handed)
No one tests the corneal reflex unless you get something weird from other testing of V, leave that to your uppers
Facial movements - you are actually testing strength, so just having them squeeze their eyes closed doesn't cut it, you want them to squeeze their eyes shut and resist you opening them with your fingers, raise & lower eyebrows, smile & show teeth is good, puff up their cheeks and not let you "push the air out"
Hearing - most will just do finger rub, using the forks takes too long and I would only do if they have a specific hearing complaint
I also carry around individual tongue depressors if I can't see soft palate elevation otherwise
For spinal accessory, pushing down on their shoulders is not enough, have them turn their head and push against your hand as well to test sternocleidomastoid
When you look at someone's tongue for fasciculations, you theorectically gotta give it a little time to show up, have them put tongue to cheek and not let you push it

To be continued
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Last time we covered cranial nerves

In my experience, having an order and a SCRIPT helps a lot

I would walk in, tell them I want to do a neuro exam, and that it "will be a lot like simon says." I ask them to "watch the tip of my penlight," with it off, and do the X & H, and then hold it in the middle and come towards their nose to check convergence & accommodation
then "I'm going to shine my light in your eyes" and would shine my light in both eyes, and do the swinging penlight test for afferent pupillary defect
then I do visual fields with finger counting. I tell them "look at my nose, not at my fingers. I'm checking your peripheral vision so only look at my nose. Count my fingers." Maintain eye contact the whole time will encourage them not to look elsewhere, and you'll know if they cheated.
here I may skip acuity and save for the end if I have time, or if I'm doing a neuro rotation DO IT with Maxwell's
I lightly touch their face in the 3 zones and ask if it feels normal and symmetric, "does it feel pretty normal and pretty similar on both sides?"
I put my hands in place and ask them to "bite down" and "move your jaw side to side," if you make the motions with them the exam goes faster
the I tell them to "squeeze squeeze your eyes closed keep them closed and don't let me open them" and the rest of the face movements
then do finger rub in each ear seperately, "should sound about the same"
I have them open and say "ahh" (if you use a depressor, set it somewhere clean and you can use it for sharp sensation later)
then I tell them to "shrug your shoulders but keep them up and don't let me push down"
then "I'll have you turn your face to the side, and don't let me move it when I push"
"stick your tongue out, move it side to side"
then I do the fundoscopic exam (to save the blinding for after I'm done being all up in their grill, so that is a little out of order)

Now, I do motor exam
Remember to push and pull hard, they should be about as strong as you in casual testing if they aren't seriously withered or tiny humans. Whatever size limb you are testing is the size of the limb you should use to test (use your biceps and triceps testing theirs, only use your wrist flexors to test theirs, use your fingers to test finger abduction)
Test both arms for tone, I won't describe how to do that, look at a video online or just watch a neurologist it's a cool "secret handshake."
Deltoids (I tell them to put their arms up like "this," then do chicken wings), then I show them how to "put up their dukes," and I wrap my hand around their wrist while I place the other flat under their upper arm, and I tell them "pull me toward you and push me away" (biceps and triceps). Be sure to use your hands with common sense to stabilize the joint for which you are testing the muscles the move the joint. (Then I have them hold their fists at their sides and check internal and external rotation strength at the shoulder. "Don't let me pull them out don't let me push them in." Not usually part of the neuro exam but usually is for a more complete musculoskeletal exam, there is so much overlap to a good neuro exam and a good musculoskeletal one I go by the combo I was taught by a physiatrist for motor)
then I test wrist flexors and extensors being sure to stabilize their forearm with one hand above or (or the strength/weakness of other muscle groups can influence your result). "Don't let me bend your wrist."
Test grip strength by having them squeeze your index and middle finger as hard as they can (they can't damage 2 but if you get them 3 they can!), have them spread their fingers and not let you push their pinky and index finger together. "Spread your fingers like this and don't let me push them together." I have them lay their palms flat and I say "hands flat like this, thumbs to the sky" while showing them, "don't let me bend your thumb" (testing opposition).
Lower extremity testing is best done with the patient reclined, but you can get away with doing it seated for speed. Just so you know in case you get yelled at for doing it one way and not the other.
I tell them lift their knee don't let me push (I lift my knee a little too so they get the hint, it's a weird motion to do sitting so show them what you mean). Once you have done this you can put your hand under their leg and tell them not to let you pull up and they'll understand. "Don't let me pull your knees apart, don't let me push them together."
I wrap my hand around their ankle and say, "pull me toward you," then "kick me away." That particular phrasing works best for me.
For dorsiflexion, I tell them to "push down on my hands like pushing on the gas pedal," and then I tell them to "lift your toes to the sky but don't let me push them down" (by now they understand simon says, for some reason testing dorsiflexion is the one that is hard to communicate to them.) If you are really fancy you will check the strength of their big toe's extension. While you're done there is a good time to check tone, move their lower leg back and forth till they relax then suddenly pull it straight quickly. This can also test how accurate a positive straight leg raise was laying down, theoretically sitting up it should be positive as well, however these Waddell signs aren't the most accurate so don't be too quick to brand your patient a liar).

Then I do reflexes. I start from the top.
I start with biceps, triceps, look to see online the best way to hold people's limbs to get the reflex.
Best technique you place your fingers over the tendon and hit your fingers NOT the patient to elicit. In any case, even if you are experienced in knowing just where to hit, palpating these tendons is never a bad idea anyway (nodules, tenderness, etc, can be clues). This is less scary to them and will hurt your fingers and not them. Plus you will be able to feel a contraction even if they are too weak for contraction to move anything distal. I tell them to "let me hold your thumbs" and holding both thumbs in one hand I shake both hands in their lap until they're totally relaxed and mostly pronated, and then I tap for brachioradialis, about half way between the elbow and wrist as it crosses over the edge of the radius. Holding the thumbs lets you detect any movement from this reflex more easily and lets you feel how relaxed the patient is. It's quick. Less painful, more gentle, you place your hand over the forearm and strike your proximal phlanges, This is considered less precise because the placement of your hand the strike can be activating any number of wrist extensors and not just brachioradialis. I see neurologists do this technique when they're in more of a hurry / ???.
I do patellar, than I place my hand on the inside of the thigh and strike to check adductors. You don't have to but many neurologists will notice that you have done this. Ankle is always done best with you dorsiflexing the foot. I find it easier if they can cross one leg over the knee to give me room to strike. Also check for clonus, and tone as you manipulate their foot. Now I check for plantar flexor response since I like to group it with all the reflexes I checked. If you are having trouble getting the patient to relax for reflexes look up reinforcing manuveur. I can't believe I'm writing all this now, I'll be damned if I'm going to illustrate it.

Now, some won't agree with my order, but I then do sensory as a separate part of my exam. Usually I'm in a position to quickly test the spot between their big toe and the second toe by touching (corresponding to L5 nerve root typically, and a commonly impinged), I use my tuning fork on the interphalangeal joint of both big toes, continue moving proximally until they feel it (medial malleolus, patella. If they don't feel it there just quit for now lol). I can easily brush the inside and outside of the lower and upper legs to test sensation, I touch my fork to see that it feels cold and test that it feels cold to the patient in one spot on the inside and outside of their upper and lower legs. I then do the same light touch, vibration, and cold, and sharp testing when I stand up and test their arms
(People will argue that if cold is intact you don't need to test sharp/ pin prick unless there are abnormalities. Otherwise add in that you can poke them with a fresh swap or tongue depressor you've snapped in half for "sharp." If they have any cauda equina/bowel/bladder complaints you may need to test for saddle anesthesia etc).
(Vibration is usually lost sooner in peripheral neuropathies so I like to have a fork and use it, because I see DM and alcoholism a-plenty. Using the big toe for proprioception is iffy in my experience, and there's a proper technique as well. One, you should hold the toe gently by the *sides* not having a finger on the pad or the nail, because they can still use *pressure* sensation of you moving the toe up and down to know its position, and that wouldn't be a true test of proprioception. Again, the argument can be made if you tested vibration and it was intact that you don't need to test proprioception in the toe, as was the case for cold/hot/sharp. However, if you find abnormalities you definitely have to test further).
(That said, you don't need to test every dermatome or waste a lot of time with two point discrimination etc. I'm telling you what to know how to do in a first pass on any neuro patient day 1 to look like you know what you're doing.)

Then I do coordination.
Finger to nose (which is also best explained by touching your nose then your finger, be sure to make them reach all the way out and move your finger a great deal), rapid alternating hand movements, "finger taps", each finger to the thumb in succession. Heel to shin which I demonstrate to them. Heel to shin is more accurate lying down then sitting when gravity is able to help.

Have them stand, without using the chair supports if they can. If appropriate check their spinal flexibility and strength by having them bend over, lean back, and bend to each side. Ideal gait test you have them walk about 20 feet in a hallway, cheaters will just do the length of the exam room. You should be sure to do it in the hallway and only defer to do with an upper if they are in danger of going splat even with 2 person assist (you and a nurse). Same goes with heel to toe. Don't let people go splat. Then have the walk on heels and walk on toes (I demonstrate walk on heels).

Romberg. Feet together standing. Close their eyes, but let them know if they feel like they are going to fall over to open their eyes!. You're supposed to do this for 30-60 seconds, but no one ever does. Again, don't let them go splat.

Tug/pull test. A lot of people add this on to the Romberg, only they have the patient stand feet normal width apart, eyes closed, and tug from behind. You can start with a little tug but most people you need to not be gentle for this test to have any meaning.

No one tests for pronator drift correctly. Most will just have someone close their eyes with both arms held in front of them palms up for a few seconds to see what happens. Good enough for you and for me to write ATM.

The chapters on Head & Neck, as well as Musculoskeletal, and Nervous system, in Bates are most useful. Most of what I didn't tell you that I'm going to tell you to know is in Bate's. It's good to have a good grasp of the musculoskeletal exam and joint exams in neuro because there can be overlap and you want distinguish where in the nervous system the pain is being generated (CNS vs PNS) and what if any role joint dysfunction is playing.

Bates is nice because it will cover the exam for comatose patients.
I didn't cover discriminative sensations or mental status or stroke assessment. Learn that stuff.
Know your nerve roots for reflexes, motor, sensation.
Know your common stroke types. Know your vascular territories and corresponding findings.
Know the differential for syncope and how to distinguish syncope from seizure.
Know your different seizure types and common causes of seizure. I don't remember how well you were expected to know the pharmacology. From what I remember they want you to know all the common seizure drug mechanisms of action, contraindications, interactions, side effects, and it seemed like you needed to know what would be first choice drug for seizure type, but you were not expected to know much re: multiple drug control
Know indications/contraindications for TPA etc.
Learn by googling how to take a good "headache/migraine" history. Bonus if you learn some pharmacology related to it.
Know about the Epley and Semont manuvers for BPPV
(hint I always distinguish "dizzy" from patients with, "felt light headed like you might pass out vs the room was spinning around you". ALWAYS.)
Know your eponymous neuro diseases well re: sx and some pharmacology, Parkinson's, Myasthenia, Lewy-Body, Alzheimer's, Guillan Barre, also multiple sclerosis
There's more to know but this is what I would want to start 3rd year rotation knowing in clinic/rounds to not look like a *******.

Be sure to have a penlight & a good reflex hammer, my fave hammer is the Prestige Telescoping and you can get for $10-15 off Amazon (the neurologists loved it)
DON'T forget to test the plantar flexor response, a lot of hammers have a pointy end to use to test for this

Definitely have the big tuning fork 128 Hz - can also find it on amazon for $10
Touch the side of your fork to your hand to see that it feels cold, then you can touch it to a patient's upper and lower arm, and inside outside of both upper and lower leg to determine sensation to cold intact & symmetric
I would carry sterile indivdually wrapped Qtips, they can be snapped to provide soft/sharp

I'm sure I missed stuff you should know

My advice, print off my "script", and practice doing the cranial nerve exam start to end until you have a "script"/system of your own down. Then practice doing the motor, reflex, sensory, coordination, gait, balance testing, in as small of chunks as you need to master each section. The more systematic and scripted the faster it will be. Eventually you will be able to do everything I described above quickly, efficiently, without missing anything, and you will look confident and knowledgeable, also because when you get pimped on the physical exam you will be able to relate some of the factoids I included here for why you may be using a certain technique. Remember in neuro there is frequently more than one way to test any given thing and each neurologist will have their own quirks.

Learn what I told you, on your rotation you will start to learn what parts of the exam you can adjust to target certain complaints.

Showing that you take the neuro exam seriously and have it down to a science will go a long way to impressing and making the poor underappreciated neurologists feel like you appreciate their specialty
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Definitely get a handle on "sciatica" (true sciatica would be inflammation of the sciatic nerve itself, which is usually not very common. what most people are referring to is some sort of lumbosacral radiculopathy, this is a common pimp question) inside and out

Also cauda equina a true neurosurgical emergency
@Crayola227 As someone who is strongly considering neuro, I think your write-up is gold. I only have one more addition -- you mentioned it, but I would start with the mini-mental status exam before the CNs. The "real" MMSE is a bit long, but it's easy to do a quick assessment by ensuring a patient is at least alert and oriented x 4 (person, place, time, situation) and has intact short term recall (repeat after me: apple, table penny...5 minutes you remember the three words I had you repeat earlier?).

No med student is expected to know how to do a LP on day 1. Ask a resident to see one, then do one under his/her supervision if you feel comfortable with the procedure. Have fun, neuro is invariably interesting.
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Neurologists love lesion localization. So, in addition to the nice summary of the neurological exam above, brush up on neuroanatomy.

Also, look at the images yourself. Don't just read MRI and CT reports.
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Edit: Crap, didn't check the date. Hope your clerkship went swimmingly!

This is my pet topic. I did multiple neuro Sub-Is and was almost going to apply for neurology.

You need to more specific about what you'll actually be doing in your clerkship. Outpatient? Stroke? General inpatient? I can provide resources for any and all, but each one is very different. If you spend a week learning how to localise strokes, review CT/MRI neuroanatomy, and then end up spending most of your time in outpatient, your week will have been largely wasted (from a clerkship point of view).

In general:

1. Learn how to perform a proper neurological exam. The Harrison's Neuro Exam videos are the best. The one for cranial nerves is outstanding (below). Same with mental status. If you want to pursue this speciality, I also recommend "Aids to Examination of the Peripheral Nervous System" and Patten's "Neurological Differential Diagnosis" to learn neuraxial localisation. Practice, practice, practice. Find a partner and spend a solid weekend until you have the examination cold. It's incredibly impressive when you can pull off a crisp and polished neuro exam in front of an attending. Neurologists take their exam very seriously.

2. Learn how to document a proper neurological exam. Same tips for all SOAP notes apply (be clear to distinguish subjective data from objective data from interpretation). I used a template from Wash U.

4. If you want to pursue this speciality, get a (used) copy of the Mass Gen Handbook. It's simply the best and has anything and everything, including tailored H&Ps and work-ups for common presentations. I found Rapid Response to be unhelpful for third years. You don't really need to know, for example, the details of the DHE protocol, and every institution is different anyways. I'm not familiar with Maxwell's. Memorise the Rule of 4.

5. You'll likely be doing zero procedures unless you're very keen. Junior residents need all the practice they can get with lumbar punctures, so they'll likely be handling those (and it's usually left to the ED for acute presentations).

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Hi everyone!

I was wondering how to do well on the Neurology clerkship-- not just resources for preparing for the shelf. Due to a different curriculum, I haven't done a physical exam in about 3-4 months. Yikes.

1) Do you recommend having a pocket book to refer to? If so, which one (MGH, Rapid response etc.) Do you actually have time to refer to these books and are they useful? Or would any down time that you have to refer to these books be better invested in doing UWorld questions for the shelf?

2) What resources did you use to learn how to perform a concise and precise neuro exam? (It's been a while lol...)

3) What sorts of things do the residents expect you to be able to do? Some people have said lumbar punctures, which I've never done!


I'd like to let you know about a new textbook which I wrote specifically written for the neurology clerkship:

Raven Review: Clinical Neurology for the Medical Student Clerkship - available on Amazon

It starts out with an overview of neuroanatomy, the neuro exam, and neuroimaging, and then has topic based cases with questions and discussion - very practical, but also covers necessary information for the shelf exam. There are lots of images and explanations of key topics at the start of each chapter. I think you'll find it a good, stand alone resource for the neurology clerkship.
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