Your principal goal during the clerkship should be to learn to do a reliable screening exam. You may wish to consult some of the books available on this topic; a few are listed below in Book List for Clinical Years below. The neurology clerkship is the ideal time to get this practice, because you will be seeing many patients with both normal and abnormal findings.
Abnormal findings will become more obvious with practice, and you will learn to recognize them via observing attending neurologists and residents perform the exam. Ask them to watch you examine patients, as they can then provide you with feedback on your technique and findings. In order to perform a thorough and comprehensive neurologic exam, some tools are necessary. We suggest obtaining a reflex hammer, tuning fork s , eye chart, penlight, and sensory instruments e. It will be very helpful for you to also have an ophthalmoscope, unless they are widely available at the bedside of your hospital, clinic, or school.
A stethoscope is also very important e. A red object e. Many students also find it helpful to have an NIH stroke scale readily available and a pocket reference book with them in their lab coats.
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A list of some available books is also listed below. Learn to Localize With all medical problems, the first step in diagnosis is determining where the problem is. This can be especially tricky with neurological symptoms, because nervous system 5. For this reason, neurologists make a big deal about neuroanatomical localization. You may also wish to consult textbooks that cover this topic. Review big-picture stuff—you will have plenty of opportunities to learn the details during your rotation.
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Imagine You Were First on the Scene Each time you begin a new clerkship, you face the daunting task of learning a new system, with new people, new procedures, new forms, and new expectations. Ask your clerkship director for an outline of your expectations while on the rotation. You must learn your role in the team, and do your part to facilitate efficient patient care.
Would I have realized the patient had a neurologic problem? What tests would I have ordered?
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What treatment would I have started? Try to localize the lesion based on your history and exam, and then generate a differential.
Use your laboratory and ancillary studies e. It is important to realize that a well organized and methodological approach is essential for arriving at the correct diagnosis. It should be your goal to arrive at the diagnosis without unnecessary tests that put the 6. Approaching clinical neurology in this way also helps to make solving the diagnostic puzzle fun and exciting. Unless you choose neurology for your career, it is far less important for you to know how to treat a patient with refractory epilepsy than it is for you to know how to recognize seizures in the first place.
You will probably never be responsible for treating brain tumors, but you are very likely to encounter patients with headaches, and you need to know how to distinguish benign headaches from those caused by structural diseases. Ironically, many of the patients you see during your neurology clerkship will be far beyond the point of initial presentation. In most cases, by the time patients see a neurologist they have already been evaluated by one or more physicians and a neurological problem has been recognized.
In some cases, you will be seeing patients, whose diagnosis was determined long ago, who present for routine follow-up or for an acute management issue. For such patients, you must balance two objectives. On one hand, you want to do your part to help your team deliver efficient patient care. Read, Read, Read This advice applies to all of your clinical clerkships. Patient care is absorbing and time- consuming, and it is easy to become so caught up in it that you neglect to read.
Indeed, time constraints may prevent you from ever having a block of several hours at a time to read a book in the usual way. A variety of textbooks are available.
Most clerkships provide a list of required or recommended books. You should be sure to read about the topics relevant to the patients you are following. Of course, you will not have the opportunity to see patients with every possible neurological problem; over the course of the clerkship you will also need to learn about the entire spectrum of clinical neurology.
You should do this sooner rather than later, especially if you may be interested in applying for neurology residency. Spending time on an inpatient ward service may be the most worthwhile, although if this is not possible, spending time as a member of the neurology consult service or in the outpatient clinic shadowing a neurologist are also reasonable options. Advice For Students Searching For Advanced Training in Neurology In addition to an introductory neurology clerkship, many schools offer the opportunity to elect specialized or advanced training in neurology, usually during the fourth year.
Examples include rotations on inpatient, consultation, or outpatient neurology services often similar to the introductory clerkship, but with greater responsibilities and expectations for the student ; rotations with a specialty service e.
In addition to the opportunities available in your own institution, you may wish to explore the possibility of doing an elective at another medical school. This is an excellent way to broaden your exposure to various styles of training and may help you later decide about which residency program is best suited for you. Here are some resources to consider: Advanced 4th year electives. Explore your interest in neurology and get to know more neurologists. The AAN has a directory that includes clerkships across the country—find more details on the Clerkship page.
Find out if your school has assigned neurology mentors—or simply identify some for yourself! The older and wiser. Upperclassmen, interns, and residents can be excellent sources of practical, need-to-know advice.
Keep perusing the AAN website. You can find a lot of helpful information on AAN. Here are a few hints: 1. Ask your fellow students who have done the rotation before. Students at your school have probably adopted one or two books for each rotation that most people end up using. Consider holding off on that big textbook purchase until your internship. Residency programs often endorse one in-depth textbook. And you may even score a free one! Go to the student bookstore and browse the books.
Think realistically about your goals for the rotation and how much reading material you will be able to cover. Blueprints in Neurology. If a health center does not refer, it is a bad health center, and a bad nurse. Healthcare providers distinguish several barriers that they associate with the referral of patients from the health centre to the zonal hospital.
The travel distance from the village where patients live to the referral hospital is usually such that patients become discouraged and may not follow-up on the referral since they lack means of transportation. There are also patients who tell me 'I have no money'. Me, I referred a patient recently, I gave him a referral letter, he tore it up and returned to his village. Another factor that affects referral is cost.
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Healthcare providers say medical care is perceived to be more expensive at the hospital than at the health centre. Patients are therefore reluctant to go to the hospital since they fear they will need to spend more money, not just for a consultation, but also for laboratory tests, medication and possible hospitalization.
The cost of hospitalization is not within the reach of villagers. We documented a case of a patient refusing referral because of cost considerations as part of the consultations that were observed. From the observation notes: " He the nurse told the family member that referral of the patient was necessary. The drug he gave the patient is only diazepam.
He prepared a transfer letter for YasaBonga, but the family refused due to lack of money. A final barrier to the referral process that was identified by healthcare providers concerns the patient's interpretation of the act of referring itself. The need for referral might be perceived as a failure on behalf of the healthcare provider -and modern medicine- to be able to resolve the health issue. In such cases the patient's carers might consider alternate, folkloristic, reasons to explain the failure.
The cause is usually sought in the patient's family and might be related to an unresolved feud or other imbalance in the patient's immediate environment.
This issue would have to be resolved first before the patient would travel to the referral hospital in the hope that this will avoid an additional medical failure. If they return from the hospital without a solution, that is to say that there is a problem in the village, witchcraft, maybe the uncle is involved, so they say that if the healthcare provider refers, it is because there is a problem in the family.
This study shows that the diagnostic work up of a neurological syndrome case in rural hospitals in DRC is largely based on the clinical presentation, without any laboratory or imaging confirmation. This quasi absence of diagnostic confirmation is explained by several factors; the general lack of specific and adapted diagnostic tools, the unaffordability of such diagnostic tests, the long turn-around-time between sample taking and result and last but not least the perception that the community has of the care provider, who is expected to diagnose the underlying problem much in the same way as a diviner would do.
This role expectation has roots in the local tradition where the disease is considered not merely as a biological phenomenon but also a social and spiritual phenomenon. In this system, the traditional healer is invested with supernatural powers and communicates with spirits to identify the sorcerer who caused the disease: someone in the community who cast a spell on the patient. Importantly, the patients and relatives consider the neurological syndrome as a supernatural phenomenon belonging to the domain of witchcraft  — .
This attitude of the clinicians can be explained by the fear of losing authority being someone who needs to know all what is in textbooks and maybe also by patterns instilled during the undergraduate training where students are expected to remember everything by heart, and opening a textbook is seen as cheating.
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