NEURO INPATIENT

Introduction

The Neurology inpatient experience consists of one 4-week inpatient rotations in the PGY1 year. The resident has primary responsibility for the inpatients on the acute Neurology service during the rotation. They will actively participate with admissions to the inpatient Neurology service. Call coverage will be part of the rotation and scheduled by the Neurology and Internal Medicine service. Upon completion of the rotations, the resident should demonstrate competence in the medical management of the common acute neurological problems, most importantly stroke management.

Medical Knowledge

The resident will:
1. Discuss the Epidemiology of various neurological disorders.
2. Discuss the clinical, laboratory, and radiologic features of, pathophysiology related to, assessment of, complications related, to diseases, disorders and problems: Stroke (implications of anatomical location and clinical presentation of various types of strokes including Thrombotic, Embolic, Lacunar, Intracerebral, and Subarachnoid); SIADH; Reflex sympathetic dystrophy; Other electrolyte imbalances; DVT; Metabolic bone disorders (e.g. osteoporosis); Critical Illness Polyneuropathy / myopathy; Other neuromuscular disorders (e.g. MS, ALS, GBS, Myasthenia Gravis); Adhesive capsulitis; Lesions of the rotator cuff; Subacromial bursitis; Subacromial impingement; Bicipital tendonitis; Wrist pain; Geriatric patients; Functional deficits; Swallowing problems (including dysphagia evaluation); Bowel and bladder dysfunction; Nutritional needs of rehabilitation patients; Speech/language disorders; Visual field deficits; Impulsivity; Normal and abnormal gait, gait patterns and other motor abnormalities; ;Aspiration; Contractures; Cognitive deficits; Self-care and ADL status
3. Discuss the basic concepts of acute stroke management: Immediate management; Blood pressure management; Seizure management; Intracranial pressure management; Thrombolytic therapy (inclusion and exclusion criteria); Anticoagulant therapy; Carotid endarterectomy (CEA) treatment; Subarachnoid hemorrhage management; Arteriovenous malformation (AVM) management.
4. Discuss the different diagnostic studies for the evaluation of stroke syndromes (CT, MRI/MRA, Carotid ultrasound, Angiography, Lumbar puncture, and Echocardiogram).
5. Describe risk reduction strategies for the above disorders, alone and in combination with these co-morbidities: Hypertension; Diabetes; Lipid abnormalities; Obesity; Smoking; Other substance abuse.
6. Discuss the use of: Pharmacological agents for the reduction of risk of recurrent stroke; Indications for surgical referral for carotid endarterectomy; Indications for surgical referral for feeding tube placement; Indications for surgical referral for intracerebral hematoma; Indications for surgical referral for subarachnoid hemorrhage; Indications for surgical referral for intracerebral aneurysm; Management of the hemiplegic shoulder and neglect.
7. Demonstrate competence in knowledge of the neurological exam.
8. Describe uses of, complications related to and general costs of commonly used devices: CPM; Knee immobilizers; Antispasticity splints; Resting splints; AFOs; KAFOs; Indications for inpatient rehabilitation admission and alternative delivery systems of rehabilitation services and their implementation.
9. Describe the clinical presentation and pathophysiology of the following: Adhesive capsulitis; Lesions of the rotator cuff; Subacromial bursitis; Subacromial impingement; Bicipital tendonitis; Wrist pain.
10. Describe in detail the physiologic changes that occur with bed rest regarding cardio-vascular changes, and changes in muscle, bone and joints.
11. Discuss normal cardiovascular response to exercise, including isometric and isotonic; upper and lower extremity endurance activities; supine versus standing positions; effect of exercise training on these parameters.

Patient Care

1. Discuss the treatment, in the inpatient rehabilitation setting, of: Stroke (implications of anatomical location and clinical presentation of various types of strokes); SIADH; Reflex sympathetic dystrophy; Other electrolyte imbalances; DVT; Critical Illness Polyneuropathy / myopathy; Other neuromuscular disorders (e.g. MS, ALS); Geriatric patients; Functional deficits; Swallowing problems (including dysphagia evaluation); Bowel and bladder dysfunction; Nutritional needs of rehabilitation patients; Speech/language disorders; Visual field deficits; Impulsivity; Normal and abnormal gait, gait patterns and other motor abnormalities; Aspiration; Contractures; Cognitive deficits; Self-care and ADL status.
2. Demonstrate competence in formulating and managing the patient’s treatment plan in an acute setting.
3. Describe prevention, evaluation and management of deep venous thrombosis and pulmonary embolus.
4. Write an appropriate therapeutic prescription plan for all rehabilitation disciplines including but not limited to occupational therapy, physical therapy, speech therapy, nursing, social service, and neuropsychology.

Interpersonal and Communication Skills

1. Present information to patients & other care team members in an effective manner. 2. Establish trust and maintain positive rapport with patients, caregivers & family members. 3. Demonstrate effective listening skills. 4. Promote teamwork in the clinical setting. 5. Complete dictations and chart notes in a legible & timely manner.

Professionalism

1. Demonstrate sensitivity and responsiveness to age, culture, disability and gender of patients and colleagues. 2. Consider effects of personal, social and cultural factors in the disease process and patient management. 3. Demonstrate reliability, punctuality, integrity and honesty in all interactions with patients and colleagues. 4. Accept personal responsibility for own actions & decisions. 5. Apply sound ethical principles in practice (e.g., informed consent, confidentiality, veracity, provision or withholding of care).

Practice-Based Learning and Improvement

1. Demonstrate skill in supervising junior residents and medical students in information gathering, decision-making, and patient management. 2. Evaluate and/or modify own practice, incorporating feedback from others. 3. Use information technology to appraise & assimilate evidence from scientific studies to enhance patient care outcomes.

Systems-Based Practice

1. Summarize the physician’s role in advocating for patient care needs 2. Summarize the physician’s role in disease management across various levels of the health care system in a cost effective manner. 3. Demonstrate how to access various community resources on behalf of the patient. 4. Demonstrate integrity and responsibility in interactions with insurance and/or disability-oriented agencies.