No one will expect too much from you honestly. Just learn how to
do a good neurologic exam (<-- link) & ask a lot of questions to patients so you can help your senior narrow the differential. Neurology is typically fairly boring with spurts of super interesting cases (as in any field).
Big things you'll see on stroke are altered mental status (usually no true localizing features on exam, typically due to an infection), functional neurologic/conversion disorder (give-way weakness, coachable strength, not localizing, young women), seizure with post-ictal Todd's paralysis, migrainous phenomena (young women, associated headache, positive symptoms like paresthesias, visual phenomena, olfactory hallucinations, light/sound sensitivity, nausea & vomiting, but keep cerebral venous sinus thrombosis on your differential [need CTV or MRV to rule out]), BPPV/peripheral neuritis/labyrinthitis (learn the HINTS+ exam to look like a boss), recrudescence (recurrence of prior stroke symptoms due to underlying infection or toxic/metabolic etiologies), alcohol intoxication (yes, ugh), & true occasionally real stroke (hemorrhagic or ischemic). There are others like like brain metastases, hemiplegic migraine, amyloid spells (cerebral amyloid angiopathy-related inflammation), PRES (basically hypertensive emergency, usually have seizures), RVCS (similar to the prior), CNS vasculitis, or CNS lymphoma.
Learn the
NIHSS (<-- link); it's very easy & very gross. Learn the major tPA inclusion & exclusion criteria (or keep a card with you). Review the basics of
CT, CTA, & CT perfusion imaging (<-- link) & understand what an
ASPECTS score (<-- link) is (don't be expected to come up with the score). MRI for stroke is super easy, but sequences can be different depending where you go, so just ask your senior which ones to look at to diagnose stroke (it's EXTREMELY easy on MRI); typically you look for brightness on diffusion-weighted imaging (DWI) & darkness on apparent diffusion coefficient (ADC). Think D
WI =
White & A
DC =
Dark (means there is restriction of water in that area, which is typically due to stroke in these contexts). You typically start with a CT noncon to rule out hemorrhage to evaluate whether it's safe to give tPA (within 3-4.5 hours), this is usually coupled with a CTA to evaluate for a large vessel occlusion with perfusion studies to see how much penumbra is theoretically present to save with a mechanical thrombectomy via neurosurgery (24 hour window here).
Inpatient general is another whole beast. Expect lots of seizure & status epilepticus evaluations, altered mental status, numbness + weakness (usually more so peripheral neuropathies), multiple sclerosis, rapidly progressive dementia (it never is), myasthenia exacerbations, & placement for any decompensating "neuro" patient. I'd focus mainly on how to get a good H&P for epilepsy, such as seizure semiology (aura, what it looked like, how it spread, how long it lasted, tongue biting, urinary incontinence, frequency, stressors, alcohol use, sleep deprivation), current AEDs (& if taking regularly), prior AEDs, infectious symptoms, changes in medications (that may alter AED absorption), etc.
I honestly don't feel like continuing to add stuff as this was already probably overkill. Just do the full neurologic exam & trust what you find (only then will you find out if what you're doing is wrong). Try to localize as best you can (eg, muscles, NMJ, peripheral nerves, spine, brainstem, subcortical, or cortical brain). Read about the diseases you see on UpToDate to get a basic idea of what to ask, what to look for, diagnostic criteria (these are not hard & fast typically), & treatment options. Don't be afraid to ask questions.
Feel free to ask more questions if they come to you.
