As many medical schools introduce neurology as a clerkship into the third year, many medical students wonder how to perform well on this rotation. Between the myriad of drugs, lesions, the neurologic exam, and neuroimaging, neurology can be a daunting clerkship for medical students. If you are looking for a vetted method for succeeding in this challenging clerkship, look no further. The neurology clerkship will provide students with the fundamental clinical neurology knowledge all medical students should possess. Whether you are considering being a neurologist, a neurosurgeon, or just want to perform well, this guide will provide you all the tips you need.
First, let’s talk resources for the neurology NBME shelf. The most useful ones are listed below.
Uworld Step 2 CK Nervous System Questions
Previous NBME Exams
Case Files Neurology
DaVinci Academy’s Neuroanatomy #DaVinciCases
Anki (Zanki step 2, Dorian, make your own, etc.)
The neurology clerkship tends to be short, about 4-5 weeks at most schools. Therefore, having the right resources for a challenging shelf are essential. A good strategy for the neurology clerkship is to start by learning basic clinical neurology with a resource such as OnlineMedEd. These videos are short and can be watched quickly within the first few days or week of the clerkship. After this, other videos such as the neuroanatomy and musculoskeletal #DaVinciCases videos made by DaVinci Academy can be used to gain further understanding. Combine these video resources with a book such as Case Files and you will master clinical neurology.
The most important resource, however, is practice questions. The Uworld neurology questions are good and should be done throughout the clerkship. NBME neurology practice exams can also be used. These can be purchased directly from the NBME and will be very similar to the actual shelf. These 2 resources are the most important and should not be overlooked.
The neurology shelf also tends to have questions involving internal medicine, psychiatry, and musculoskeletal. For example, musculoskeletal lesions of the brachial plexus and spine are fair game and often show up. Similarly, questions that are more about a psychiatric condition but have a small neurology component are also fair game. If you are going for honors, consider reviewing some of these topics for test day.
As with all rotations, students should show up early, and be prepared to round or see patients in clinic. Having on a clean pressed white coat, nice dress clothes or scrubs (depending on the culture of the service) are always expected. A pro-tip is to bring a clipboard, pen, and a pre-made SOAP note so you are ready to see patients. Depending on inpatient, outpatient, general neurology, or a sub-specialty, the pre-made SOAP note can have questions specific or general to that patient population. Similarly, the neurologic exam can be printed on this pre-made note. These type of pre-made notes can be purchased or typed up in a word document and printed out. This serves as a template for the student so they can remember all the important questions and take notes as needed during patient encounters. Furthermore, they can use this as a template to present to attendings later on.
The neurologic exam can be broken into the following components:
Each of these components can be tested separately and it is beyond the scope of this post to dive into the individual components. First of all, these components should either be memorized or have them on a paper when going to perform the interview. An easy way to remember the components is from head-to-toe. Many components of the exam such as speech, gait, facial droop, etc. may be assessed just from walking into the room and observing the patient. First, interview the patient, asking orientation questions such as their name, where they are, the date, and if they know why they are there. This can be extended into memory and attention questions. The student may even wish to perform the MoCA or another cognitive assessment. Next, tell the patient you will examine them, checking the function of their nerves. Start with the cranial nerves II-XII (you will unlikely assess olfactory function). Next, test their motor strength of the bilateral upper and lower extremities. Then, repeat, for both the upper and lower extremities, sensation and reflexes. Last, special coordination tests and gait by asking the patient walk can be assessed. This will depend on the setting. For example, it may not be safe to ask a patient in the hospital who had a stroke to stand and walk for you, but a Parkinsonian patient in the outpatient setting should have their gait and arm swing assessed (be ready to support them if they fall!!). The neurologic exam takes time to learn and can take students a long time to perform. Along with presenting, it is often a skill attendings will assess students with for their clinical grade.
Similar to internal medicine, inpatient neurology is all about admissions, discharges, and rounding. Be early, stay late, and ask to help the residents are some common ways to do well on inpatient services.
One way that neurologic patients differ from internal medicine patients is that many of these patients have cognitive deficits. For example, a conversation with a stroke patient with aphasia will be different from a patient with COPD exacerbation. Be prepared for patients who are unoriented, delirious, or even have neuropsychiatric symptoms. In the neuro-ICU or other high-acuity services, be prepared to speak loudly, repeat yourself, and get history from family members. It is often best to ask the nurse how the patient is doing and if you can examine them before entering a neuro-ICU room or stroke patient’s room. Better yet, have your attending or resident walk you through the neurologic exam with one of these patients the first time. To obtain your Glasgow Coma Scale or other neurologic assessments, you may have to peel open the patient’s eyes and shine light in them or even squeeze their skin to see if they withdrawal from pain. This can be distressing to the patients and their family members so be mindful of this.
Outpatient neurology is similar to most other outpatient medical practices. The interviews and examinations can be very long depending on the attending you are with. If you are rotating through a specific sub-specialty of neurology such as neuro-immunology or movement disorders, take the time to read about the conditions seen in these practices and learn the questions you should be asking before you show up for service. Also, practicing the neurologic exam with a classmate before the first day of service can help.
Each attending will have their own preference on how a student should present. Ideally, all presentations should be done in SOAP format. The subjective should tell the story of the patient in their own words or the information provided by family or emergency medical services. The objective should focus on the neurologic exam and any laboratory or imaging data that is relevant to the case. For assessment, make sure to give a summary 1-liner with a differential diagnosis. Then, explain what you think is the diagnosis and why. Up-To-Date or your resident can help you with this before presenting to the attending. Last, give a plan of how you will treat the patient. Make each part of the SOAP format obvious and don’t jump around when presenting, so the attending sees you stuck to the standard format.
The length of the presentation and how much detail to go into is an art. If the service is busy and a long presentation is not possible, keep it short. If the service is slow and there is extra time, go into all the details. A good rule of thumb is to present similar to how the residents present but with slightly more detail and emphasize the medical terminology. For example, don’t say “temperature at 103.” Instead say, “patient febrile at 39.4 centigrade.” Or for a stroke patient, don’t say “he is able to understand what I’m telling him but can’t say words to respond to my questions.” Instead try “neurologic exam consistent with expressive aphasia…” For the neurologic exam presentation, it is also important to know tone and reflexes so you can articulate what you observed.
In closing, the neurology clerkship is a fun, exciting rotation in medical school. It can be challenging, but very rewarding. Have fun, learn the neuro exam, and study hard for that shelf. You got this!
About the Author: Evan Dishion is a fourth-year medical student at Creighton University School of Medicine and is currently applying to neurology residency. He honored both the neurology NBME exam and his neurology clinical clerkship.
He also founded and runs his own company, Healthy Nerves, which explores neurology and neuroscience. You can learn more at www.healthynerves.org