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Goals and Objectives

The goals and objectives of our Neurology clerkship are adapted from the American Academy of Neurology Clerkship Core Curriculum Guidelines.

Goal

The goal of our clerkship is to teach the principles and skills to recognize and manage common neurological presentations that a general medical practitioner is likely to encounter in practice.

Objectives

By the end of the clerkship, we expect our students to perform the skills outlined below. 

Procedural skills

  • Obtain a complete and reliable neurologic history
  • Perform a comprehensive neurologic examination. See below to review the Guidelines for a Comprehensive Neurological Examination listed below.
  • Examine patients with altered level of consciousness or abnormal mental status. See below to review the Guidelines for the Neurologic Examination in Patients with Altered Level of Consciousness.
  • Deliver a clear, concise, and thorough oral presentation of a patient's history and examination
  • Prepare a clear, concise, and thorough written presentation of a patient's history and examination

Analytical skills

  • Recognize symptoms that signify neurologic disease (including disturbances of consciousness, cognition, language, vision, hearing, equilibrium, motor function, somatic sensation and autonomic function)
  • Distinguish normal from abnormal findings on a neurologic examination
  • Localize the likely site or sites in the nervous system where a lesion could produce a patient's symptoms and signs
  • Formulate a differential diagnosis based on lesion localization, onset of symptoms, time course and relevant historical and demographic features
  • Become familiar with the common tests used in diagnosing neurologic diseases (CT, MRI, EEG, EMG, Lumbar Puncture)
  • Recognize neurological emergencies (acute ischemic stroke, status epilepticus, SAH, encephalitis/meningitis, brain herniation, neuromuscular crisis)
  • Acquire an awareness of the principles underlying a systematic approach to the management of common neurologic diseases (including the recognition and management of situations that are potential emergencies)
  • Acquire an awareness of situations in which it is appropriate to request neurologic consultation
  • Review and interpret the medical literature (including electronic databases) pertinent to specific issues of patient care

Behavioral skills

  • Develop knowledge, skills, attitudes and behaviors toward learning which perpetuate lifelong learning, inquisitiveness and evidence-based practice
  • Demonstrate professional appearance, attendance and behavior consistent with that expected of a physician-in-training
  • Conduct a clinical evaluation, including history and physical examination, in a professional manner with respect to attitude and behavior during the clinical encounter
  • Begin to learn the roles of various health professionals on the patient care team
  • Make positive contributions to patient care by working collaboratively with members of a multidisciplinary healthcare team

Guidelines for a Comprehensive Neurologic Examination

The objective of neurological examination is to localize the neuroanatomical lesion as the cause of the neurological symptoms. The neurologic examination is not a simple check list. Neurologists tailor their examination based on a patient's clinical presentation and history of illness. 

The neurological examination should include the following:

  • Mental status/language/memory
  • Cranial nerves (1-12)
  • Motor function
  • Sensory system
  • Coordination and gait
  • Reflexes

By the end of the second week of the clerkship, our students will demonstrate the ability to complete a full neurological exam within 15 minutes. This will be assessed as part the SP encounter, in a clinical setting, or in an OSCE format.

A. Mental Status

  • Level of alertness
    • Alert
    • Delirium
    • Obtunded
    • Stupor
    • Coma

  • Language function - Listening for fluency of language output
    • Comprehension - Follow a simple command such as "Show me your right thumb."
    • Repetition - "Repeat after me: No ifs, ands, or buts."
    • Naming - Point to two objects and have the patient name them (Example: pen, watch)
    • Writing
  • Memory
    • Short-term
      • This can be tested in one of two ways:
        • Immediate and delayed - Have the patient recite 3 words: apple, table, and penny. Then ask the patient to repeat the three words 5 minutes later OR
        • Answer a couple of orientation questions (place, date, month, etc.)
    • Long-term - Ask the patient a question regarding a generally known historical fact. For example "Who is the president?"
  • Calculation - Simple arithmetic but not just 2 + 2. Example: "What is 21 minus 7?"
  • Visuospatial processing - Have the patient draw intersecting pentagons or a clock
  • Abstract reasoning - Have the patient interpret a proverb. Examples:
    • If you find a letter with a stamp and address on it lying on the ground, what would you do?
    • What does this mean: "A rolling stone gathers no moss," "no use crying over spilled milk"
  • Speech - Check articulation. Example: Have the patient say "po-ti-ka" which checks labial (lips), lingual (tongue), and palatal (palate) sounds. Palate rise to phonation (say "ah") and gag

B. Cranial Nerves

  • Olfactory (CN 1) Smell - Checking each nostril separately, have the patient identify a common smell such as coffee or cinnamon
  • Vision
    • Visual fields
    • Visual acuity - Using the Snellen eye chart, this should be best corrected, meaning ask the patient to wear their glasses if they use them
    • Funduscopic examination
  • Pupillary light reflex (afferent CN 2, efferent CN 3)
  • Eye movements (CN 3, 4, 6: H-test)
  • Facial sensation (CN 5) - Using your fingers or a cotton swab, test the right and left side of the face in all three divisions of CN 5
  • Facial strength (CN 7) - Check muscles of facial expression (frown/smile)
  • Hearing (CN 8) - Rub your fingers or whisper next to each ear. Do not snap your fingers, just rub them. If they can't hear the rub, click your fingernails
  • Palatal movement (CN 9, CN 10) - Observe palatal movement when the patient says "ahh"
  • Neck movements against resistance (CN 11)
    • Head rotation
    • Shoulder elevation
  • Tongue movement (CN 12)

C. Motor Function

  • Muscle tone in the arms and legs (resistance to passive manipulation)
  • Bulk - Observe for atrophy, etc.
  • Strength
    • 0: No muscle contraction
    • 1: Trace visual or palpable movement
    • 2: Movement with gravity eliminated
    • 3: Movement against gravity but not resistance
    • 4: Movement against resistance but can be overcome
    • 5: Normal
    • Upper extremities
      • Shoulder abduction
      • Elbow flexion
      • Elbow extension
      • Wrist flexion
      • Wrist extension
      • Finger flexion
      • Finger extension
      • Finger abduction
      • Thumb abduction
    • Lower extremities
      • Hip flexion
      • Knee flexion
      • Knee extension
      • Ankle dorsiflexion
      • Ankle plantar flexion
  • Pronator drift - Have the patient hold both arms out straight with palm up in front, close their eyes, and observe for drift downward or pronation of either or both arms
  • Involuntary movements - Observe for any involuntary movements

D. Sensation

  • Light touch - Use your fingertips or a cotton swab and test each arm and each leg
  • Pinprick or temperature - Use an unused safety pin and test each arm and each leg
  • Vibration - Use a 128 Hz tuning fork and test the distal joint in one finger on each hand and both great toes. If the patient cannot detect vibratory sense distally, then move proximally.
  • Proprioception - Test joint position sense at the distal joint in one finger on each hand and in both great toes. If the patient cannot detect joint movement distally, then move proximally.

E. Reflexes
Valid test results are best obtained when the patient is relaxed and not thinking about what you are doing. If you cannot get any response with a specific reflex-ankle jerks are usually the most difficult-then try the following:

Several different positions of the limb:

  • Get the patient to put slight tension on the muscle being tested. One method of achieving this is to have the patient strongly contract a muscle not being tested.
  • In the upper extremity, have the patient make a fist with one hand while the opposite extremity is being tested.
  • If the reflex being tested is the knee jerk or ankle jerk, have the patient perform the "Jendrassik maneuver," a reinforcement of the reflex (see Gassel, 1964). The patient's fingers of each hand are hooked together so each arm can forcefully pull against the other. The split second before you are ready to tap the tendon, say "pull."

In general, any way to distract the patient from what you are doing will enhance the chances of obtaining the reflex. Having the patient count or give the names of children are examples.

  • Deep tendon reflexes
    • 0 = no response; always abnormal
    • 1+ = a slight but definitely present response; may or may not be normal
    • 2+ = a brisk response; normal
    • 3+ = a very brisk response; may or may not be normal
    • 4+ = a tap elicits a repeating reflex (clonus); always abnormal
      • Biceps (C5, 6)
      • Triceps (C6, 7)
      • Brachioradialis (C5, 6)
      • Patellar (L3, 4 knee jerk)
      • Achilles (S1 ankle jerk)
  • Plantar responses (pathological reflexes)
  • Hoffman
  • Frontal release signs (glabellar, snout, palmomental)
  • Jaw jerk (brain stem reflexes)

F. Coordination

  • Rapid alternating movements - Finger tapping, foot tapping, pronation/supination of the hands
  • Finger-to-nose
  • Heel-to-shin

G. Gait/Station

  • Casual gait - check stride length, arm swing, turns, etc.
  • On toes - have the patient walk away from you on their toes to assess heel height
  • On heels - have the patient walk toward you on their heels to assess toe height
  • Tandem walking - have the patient walk in a straight line with heel touching toes
  • Romberg - have the patient stand with their feet touching together, arms at their sides, and eyes open, then ask them to close their eyes and observe for swaying for a few seconds

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

A. Mental Status

  • Level of arousal
  • Response to auditory stimuli (including voice)
  • Response to visual stimuli
  • Response to noxious stimuli (applied centrally and to each limb individually)

B. Cranial Nerves

  • Response to visual threat
  • Pupillary light reflex
  • Oculocephalic (doll's eyes) reflex
  • Vestibulo-ocular (cold caloric) reflex
  • Corneal reflex
  • Gag reflex

C. Motor Function

  • Voluntary movements
  • Reflex withdrawal
  • Spontaneous, involuntary movements
  • Tone (resistance to passive manipulation)

D. Reflexes

  • Deep tendon reflexes
  • Plantar responses

E. Sensation (to noxious stimuli)

Last modified: Dec 09, 2020
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