PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 16: NEUROLOGY
This section has been reviewed and approved by the Chief, Division of Neurology as well as
the Program Director, Internal Medicine Residency Program at Prince George’s Hospital
Center.
________________________
Chief, Division Of Neurology
_____________________________
Program Director, Residency Program
I. Overview
Neurology encompasses the prevention and management of disorders of the central and
peripheral nervous systems. Other conditions, such as headache, may be caused by
non-neural dysfunction but are often considered under the category of neurology.
The general internist should possess a broad range of competency in neurology.
He/she should be able to perform and interpret a detailed neurologic examination;
should be competent in the primary and secondary prevention of neurologic diseases;
and should be familiar with the presenting features, diagnosis, and treatment of common
neurologic disorders.
The general internist may encounter neurologic disorders in various settings, including
ambulatory care, hospital, long-term care, and home care. At the end of their training
Internist should be able to manage common neurological problems like peripheral
neuropathy and be able to identify neurologic emergencies like cord compression,
herniation etc. and to obtain appropriate consults. In communities where a neurologist is
not available, the general internist may be a consultant for some complex neurologic
disorders.
II. Principle Teaching Methods
It consists of frequent encounters with the attending physician regarding patient care.
The resident will discuss all patients with the attending physician and interpret clinical
data to formulate a differential. The attending will assign reading topics on a regular
basis and review the material with the residents. This will include accepted national
guidelines used in the diagnosis and treatment of various neurologic diseases. The
faculty will also critique the residents consult notes, examination and management plan.
Rounds will include short 15-30 minute discussions on current topics driven by patient
encounters and initiated by resident and completed by the attending physician on most
days. Latest information dealing with the topic as provided by literature search and
pertinent articles should be discussed.
Residents will also be required to take a one-hour test at the beginning and end of the
rotation. The test will help residents understand their weaknesses and work to improve
their knowledge during the rotation. The residents are required to report to the program
coordinator at the beginning and end of the rotation for this exercise.
III. Strengths and Limitations
The residents will be exposed to a broad range of clinical problems typical of a
community-based practice with emphasis on inpatient illness and care. The teaching
faculty for the rotation is committed to teaching and patient care with strong role model
presentation. There is on site neurological surgery, giving residents exposure to surgical
management of acute bleeds, space-occupying lesions of spinal cord and shunt
placement. ; but the increasing use of lytics and stent placement is more typical for
community based care. The hospital does not have the ability to perform stereotactic
biopsies at this time. For patients with exceptionally unusual clinical problems, the care
may require transfer to a tertiary referral center. Outpatient experience in the
subspecialty can be obtained by shadowing the attending physician in their private
office. Patients in the continuity clinic at Glenridge Medical Center also offer learning
opportunities.
IV. Goals and Objectives
Legend of Learning Activities
Learning Venues:
1. Direct Patient Care/Consultation
2. Attending Rounds
3. Core Lecture Series
4. Self Study
Evaluation Methods:
A. Attending Evaluation
B. Direct Observation
C. Nurses’ Evaluation
D. In-training Examination
E. Pre and post rotation test
Competency: Patient Care
Learning Venues
Evaluation Methods
1,2
A,B
1,2
A,B
Demonstrate the ability to develop a differential
diagnosis,
diagnostic
strategy,
and
management plan for patients with central
nervous system disorders.
1,2
A,B,D,E
Demonstrate the ability to develop a differential
diagnosis,
diagnostic
strategy,
and
management plan for patients with peripheral
1,2
A,B,D,E
Demonstrate proficiency in performing a
detailed neurologic exam, and interpreting its
results in a patient with neurologic disease.
Demonstrate the ability to interpret ancillary
tests, and radiographic studies pertinent to
diseases of the nervous system and diagnose
neurologic emergencies like status epilepticus
and cord compression.
nervous system disorders.
Demonstrate the ability to manage the care
and complications of patients with chronic
neurologic disease, including chronic pain
syndromes.
1,2
A,B,D,E
Competency: Medical Knowledge
Learning Venues
Evaluation Methods
1,2,3,4
A,B,D,E
1,2,3,4
A,B,D,E
1,2,3,4
A,B,D,E
1,2,3,4
A,B,D,E
1,2,3,4
A,B,D,E
1,2,3,4
A,B,D,E
Learning Venues
Evaluation Methods
1,2
A,B,C
1,2
A,B
Learning Venues
Evaluation Methods
1,2
A,B
1,2
A,B,C
Understand the pathophysiology, evaluation,
and
management
of
cerebrovascular
accidents.
Understand the pathophysiology, evaluation,
and management of seizure disorders.
Understand the pathophysiology, evaluation,
and management of peripheral neuropathies.
Understand the pathophysiology, evaluation,
and management of dementia, including
Alzheimer’s disease.
Understand the pathophysiology, evaluation,
and management of chronic pain syndromes,
including headaches and low back pain.
Know the appropriate indications for commonly
ordered neurology tests and procedures,
including: EEG, EMG, nerve conduction
studies, evoked potentials, lumbar puncture,
CT and MR imaging of brain and spinal cord
Competency:
Interpersonal
and
Communication Skills
Interact in an effective way with physicians,
nurses, and other personnel participating in the
care of patients.
Interact in an effective way with patients, and
caregivers of those with neurologic disease.
Competency: Professionalism
Treat team members, primary care-givers, and
patients with respect.
Actively participate in rounds.
Attend and participate in all scheduled
conferences.
Competency: Practice-Based Learning
Identify limitations of medical knowledge and
uses medical literature to address gaps in
medical knowledge
Competency: Systems-Based Practice
Understand barriers to optimal care of patients
with neurologic disease.
Attendance sheet
Learning Venues
Evaluation Methods
1,2,
A, D,E
Learning Venues
Evaluation Methods
1,2,3
A,B
Understand the need for teamwork and a
multidisciplinary approach in caring for those
with neurologic disease.
1,2,3,5
A,B,C
V. Educational Content
A. Common presentations
1) Understand the causes for presentation of patients with:
 Abnormal speech
 Abnormal vision
 Altered mental status
 Syncope
 Altered sensation or weakness
 Memory loss
 Disturbance of gait or coordination
 Dizziness and vertigo
 Hearing loss
 Headache
 Localized pain syndrome: facial pain, radiculopathy
 Seizure
 Tremor
2) Perform thorough history and physical and order and interpret results of
appropriate tests:
 Toxicology screen
 CSF findings
 Imaging studies: CT scan, MRI, carotid dopplers
 Electromyography, nerve conduction studies
 Electroencephalography, evoked potentials (visual, auditory, sensory
 Mini mental exam
 Anticonvulsant drug levels
B. Central Nervous System Infection
1) Understand the causes, presentation, differential diagnosis, and management of:
 Brain abscess
 Encephalitis
 Meningitis: bacterial, viral and cryptococcal
2) Know indications and contraindications of lumbar puncture and interpret results
of:
 Cerebrospinal fluid findings
 Imaging studies: MRI, CT scans
 Serum titers
C. Cerebrovascular Accidents
1) Understand causes, presentations and management of:
 Stroke: ischemic, hemorrhagic
 TIA
2) Recognize complications of strokes including edema, bleeding into large CVA
etc.
3) Know indications and contraindications of lumbar puncture and interpret results
of:
 Cerebrospinal fluid findings
 Imaging studies: MRI, CT scans
 Serum titers
D. Miscellaneous
1) Understand the causes, diagnostic criteria and management of:
 Benign positional vertigo
 Labrynthitis
 Headaches: cluster headache, migraines, tension headache
 Syncope
 Toxic encephalopathies like alcohol withdrawal, uremic and hepatic
encephalopathy
2) Understand the indication and role of diagnostic tests including tilt table test
E. Dementias
1) Understand the causes, diagnostic criteria and management of:
 Alzheimer’s
 Multi-infarct
 Lewy Body
 Normal Pressure Hydrocephalus
 Pseudodementia
2) Order appropriate tests and interpret results of
 Mini-mental test, cognitive evaluation
 Imaging studies
 Thyroid function
 CSF
F. Spinal Cord Disease
1) Understand the causes, diagnostic criteria and management of
 Cord compression
 Epidural abscess
 Lumbar and cervical disc syndromes
 Spinal stenosis
2) Order appropriate tests, know indications for surgical evaluation of these
conditions
G. Peripheral Nervous System
1) Understand causes and management of peripheral neuropathy secondary to:
 Systemic disease like diabetes
 Toxins like alcohol
 Infections like HIV
 Nutritional deficiencies like Vitamin B12
2) Know the indications and interpretation of results of
 Nerve conduction studies
 EMG
H. Neuromuscular Diseases/Movement Disorders
1) Understand the presentation, diagnosis and management of
 Amyotropic lateral sclerosis
 Guillain-Barre Syndrome
 Multiple sclerosis
 Muscular dystrophy
 Parkinsons disease
 Myasthenia gravis
2) Know indications and interpretations of appropriate tests including but not limited
to:
 Imaging studies
 CSF results
 Edrophonium test
 Negative inspiratory force
I.
VI.
Bleeding
1) Recognize the signs and symptoms and know the management of:
 Subarachnoid hemorrhage
 Subdural hematoma
Recommended Readings
All senior residents are encouraged to read the MKSAP for Neurology during their onemonth rotation. Questions will help develop analytical thinking. Residents should also
consult the following texts during their rotation regarding the key clinical issues in
diagnosis, pathophysiology and therapy raised by the patients they evaluate and care for
on the neurology consult rotation:
 Harrison’s Principles of Internal Medicine
 Residents are also encouraged to use MDConsult and Up To Date to read on a
case-by-case basis. Residents must also discuss latest guidelines for management
of patients with stroke.
A. Encephalopathy
1) Practice parameters for determining brain death in adults. Neurology
1995;45:1012-1014.
2) Booth C, Boone R, Tomlinson G, et al. Is this patient dead, vegetative or
severelyneurologically impared? Assessing outcome for comatose survivors of
cardiac arrest.JAMA 2004; 291(7):870-879.
3) Levy D, Caronna J, Singer B, et al. Predicting outcome from hypoxic-ischemic
coma. JAMA 1995;253;10:1420-1426. (Abstract)
4) Mangano D, Mangano C. Perioperative stroke; ecephalopathy and central
nervous system dysfunction. J Intensive Care Med 1997;12:148-160.
B. Stroke
1) Adams H, Adams R, Brott T, et al. Guidelines for the early management of
patients with ischemic stroke: A scientific statement from the Stroke Council of
the American StrokeAssociation. Stroke 2003;34:1056-1083.
2) Straus S, Majumdar S, McAlister E. New evidence for stroke prevention:
Scientific Review JAMA 2002;288(11):1388-1395.
3) Straus S, Majumdar S, McAlister E. New evidence for stroke prevention: Clinical
Applications. JAMA 2002;288(11):1396-1398.
4) Donnan G, David S. Controversies in stroke. Stroke 2002;33:2137-2140.
5) Adams H. Patent foramen ovale: paradoxical embolism and paradoxical data.
Mayo Clin Proc 2004;79:15-20.
6) Horton S, Bunch T. Patent foramen ovale and stroke. Mayo Clin Proc.
2004;79:79-88.
7) Hiott B, Lentz S. Prothrombotic states that predispose to stroke. Current
Treatment Options in Neurology 2002;4:417-425.
8) Muir K. Secondary prevention for stroke and transient ischaemic attacks. BMJ
2004;328:297-298
9) Brott T., Bogousslavsky J. Drug Therapy: Treatment of Acute Ischemic Stroke N
Engl J Med 2000; 343:710-722, Sep 7, 2000.
10) Blacker DJ - Lancet Neurol In-hospital stroke 01-DEC-2003; 2(12): 741-6
C. Seizure
1) Manno E. New management strategies in the treatment of status epilepticus.
Mayo Clin Proc 2003;78:508-518.
2) Herman S. Single unprovoked seizures. Current Treatment Option in Neurology
2004;6:243-255.
3) Kaufmann H, Bhattacharya K. Diagnosis and treatment of neurally mediated
syncope.The Neurologist 2002;8:175-185.
4) Browne T. R., Holmes G. L. Epilepsy N Engl J Med 2001; 344:1145-1151, Apr
12, 2001.
D. Headache
1) Diamond M. Emergency room treatment of migraine headache. Current
Treatment Options in Neurology 2002;4:351-356.
2) Lucas S. Initial abortive treatments for migraine headache. Current Treatment
Options in Neurology 2002;4:343-350.
3) Moore K. Management of chronic headache in the era of managed care. The
Neurologist 1997;3:209-240.
E. Dementia
1) Bolla LR, Filley CM, Palmer RM. Office diagnosis of the four major types of
dementia. Geriatrics 2000; 55:34-46
F. Neuromuscular Disease
1) Van der Meche F, Van Doorn P. Guillain-Barre Syndrome. Current Treatment
Options in Neurology 2000;2:507-516.
2) Briemberg H, Amato A. Dermatomyositis and polymyositis. Current Treatment
Options in Neurology 2003;5:349-356.
3) Bolton C, Young GB. Critical illness polyneuropathy. Current Treatment Options
in Neurology 2000;2:489-498.
4) Rowland L. P., Shneider N. A. Medical Progress: Amyotrophic Lateral Sclerosis.
N Engl J Med 2001; 344:1688-1700, May 31, 2001
G. Multiple Sclerosis
1) O’Conner P. Key issues in the diagnosis and treatment of multiple sclerosis.
Neurology 2002;59(6)(3):1-33.
2) Noseworthy, et al, Multiple Sclerosis, NEJM 343(13): 938-952, 2000
3) Corboy JR, Goodin DS, Frohman EM. Disease-modifying Therapies for Multiple
Sclerosis. Curr Treat Options Neurol. 2003 Jan;5(1):35-54.
H. Peripheral Neuropathy
1) Irving GA. Neurology Contemporary assessment
neuropathic pain.- 28-JUN-2005; 64(12 Suppl 3): S21-7
I.
and
management
of
Aphasia
1) Damasio AR. Aphasia. New Engl J Med 1992; 326: 531-539
J. Movement Disorders
1) Rubino F. Gait Disorders. The Neurologist 2002;8;254-262. (Abstract)
2) Bertoni JM. Long-term medical treatment for Parkinson’s disease. Current
treatment options in Neurology 2001; 3: 495-506.
K. Concussion
1) Kelly JP, Nichols JS, Filley CM, Lillehei KO, Rubinstein D, KleinschmidtDeMasters BK. Concussion in Sports: Guidelines for the Prevention of
Catastrophic Outcome. JAMA 1991;266(20):2867-2869.
2) Kelly JP. Traumatic brain injury and concussion in sports. JAMA 1999;282:989991.