Tips for the Neurology Clerkship

TLDR

A combination of UWorld neurology questions, neurology cards in the cheesydorian Anki deck, NBME Shelf Assessments, and Rotation Ready will be the ultimate way to succeed in the Neurology clerkship and on the Shelf Exams.

Knowing common presentations for various strokes will help you get through a good amount of the questions on the Shelf Exam, while knowing where in the neural pathways a pathology arises will help you eliminate incorrect answers.

You’re sure to impress your evaluators if you mention various stroke scales, classification criteria, and scores which are found below.

What to expect

The Neurology Clerkship at a glance

Here at RotationReady, we think the neurology clerkship is an essential part of medical education. It’s a great way to reinforce basic knowledge of the nervous system gained in the didactic phase of medical school, while seeing first-hand the oftentimes devastating impact of neuropathology, as well as it’s fascinating and ever-evolving management. Surprisingly, not every MD program requires a neurology clerkship, so if you missed out during clerkships, definitely reach out to your local Neurology Department for shadowing or for organizing a fourth year elective.

So, what is it that we loved about the neurology clerkship? It’s one of the first times students feel they can connect the anatomy and pathology they’ve learned in medical school to real-world clinical scenarios. Specifically, Neurology is all about localization, and medical students on top of their neuroanatomy can get really good at this! Localization is the process of reasoning backward from clinical symptoms to anatomy, thereby identifying where a lesion is, winning points with your evaluators, and actually helping to save lives. Thus, medical students are primed to truly contribute to the work up of patients on neurology services. Also, who doesn’t love the brain?

From what we know, throughout the United States, Neurology Clerkships are usually four to six weeks long, with weeks at a time spent on both inpatient and outpatient services. The inpatient services usually include the General Neurology Consult Team, the Stroke Team, and Child Neurology, where you will see the bulk of what inpatient Neurology practice looks like. While on the General Neurology Consult Team, you generally round on patients the team has been following in the hospital while also taking new consults from the Emergency Department or from units in the hospital where patients are experiencing new neurologic symptoms. The Stroke Team will specifically respond to stroke alerts arriving to and throughout the hospital – it’s a great time to brush up on the imaging correlates of a huge number of neurologic lesions. We felt that Child Neurology was a difficult rotation because of the devastating pathologies seen in such young patients, but it was also an incredible experience to work up new-onset seizure, as well as protect young brains in refractory status epilepticus.

Outpatient rotations can involve the long-term follow up for patients discharged from the hospital after workup for stroke, but might also include clinics specializing in Epilepsy or Neuromuscular Disorders like ALS, Parkinson Disease, etc. Most universities also offer elective weeks on their Neurology Clerkships, including anything from Neurosurgery to a week on a Neurosciences ICU.

If you will be rotating in a Neurosciences ICU (which we certainly recommend), head over here to get a detailed run down on rotating in the ICU, as well as what to expect on an NSICU in particular.

The heart of Neurology: localization

A scenario you could very well see on stroke service – and a classic exam question – is a patient presenting to the ED with a history of HTN, HLD, DM2, and CAD w/ LAD stent, complaining of seemingly random symptoms: they can’t walk normally, their face feels weird, they’re seeing double, and the nurse tells you they just choked and coughed when trying to drink some water. You’re up first to evaluate this patient, and your mind is spinning. What do you do? Localize! During your physical exam, the patient fails the finger-nose coordination test, and they for sure have one pupil that’s larger than another. Now, using your knowledge of anatomy, you’re thinking of the areas of the brain normally responsible for what the patient cannot do right now, namely the cerebellum (gait changes and failed finger-nose coordination), the spinothalamic tract (unequal pupils), and the nucleus ambiguus of spinal nerves IX and X (swallowing, speaking). You add up these deficits and they localize to a specific area of the brainstem, namely the lateral medulla, which in turn you know is supplied by the posterior inferior cerebellar artery, the PICA. Congrats, you just nailed Lateral Medullary Syndrome, a.k.a. Wallenberg Syndrome!

Of course, you probably remember learning about Wallenberg Syndrome during the didactic phase of medical school, but what’s different during your Neurology Clerkship is that you will have to ask the right questions, perform the correct physical exam maneuvers, and make the relevant observations to actually localize and diagnose Wallenberg Syndrome. Don’t fret though! With the resources listed below, RotationReady will help you bridge the gap between the neurology didactics and the neurology clerkship, as well as help you smash that big bad Shelf Exam.

Pursuing Neurology in fourth year and beyond

If you think you might love Neurology, or you just want to know more about it, click here to read about pursuing the field of Neurology as a career, written by our brilliant colleague Dr. Floyd Silva, who is currently a Neurology Resident at New York University (NYU) Grossman School of Medicine.

Resources for the Neurology Clerkship

Both Ben and Dev scored 97th percentile on the Neurology Shelf Exam, and as always at RotationReady, we don’t just list the resources below, but detail how we used each of them to get ahead of the pack.

Physical exam

When on the Neurology Clerkship, whether inpatient or outpatient, we noticed Attendings really wanted to see us perform thorough physical exams, and the neurologic exam can be intimidating. What worked best for us was to remember the major categories of the neurologic exam, then perform them head-to-toe. Keeping in mind that, for a thorough exam, you’ll need to test six categories – mental status, cranial nerves, coordination, sensory, motor, and gait – look at your patient and move from

Here is a link to a thorough physical exam checklist for your Neurology Rotation. We recommend reading over a list like this – even if you only walk away with the basic skeleton of the exam, it will keep you organized and on point.

Here is a link to a resource-heavy website called NeuroLogic Exam, hosted by the University of Utah. On this website, you will find a plethora of videos that demonstrate physical exam maneuvers, normal findings, and abnormal findings, organized by the major categories of the neurologic physical exam. There are also 10 great quiz questions for each of the six major categories of the physical exam. You will not waste time clicking around on this website, even if the videos posted are from a time when video camera technology was just invented.

Scores and scales

Here is a list of some of the scores and scales that Attendings loved to hear about and to ask questions about when on the Neurology Rotation. If you’d like a deeper dive, click the links below to find the landmark publications that validated these scores. Use MDCalc to calculate these scores.

1. The Glasgow Coma Scale (GCS) is used to assess the level of consciousness in a patient who has suffered a head injury. It measures eye-opening, verbal response, and motor response to stimuli, with scores ranging from 3 to 15.
2. The National Institutes of Health Stroke Scale (NIHSS) is used to assess the severity of stroke in a patient. It evaluates various neurological functions, such as language, sensation, and motor ability, with scores ranging from 0 to 42.
3. The Modified Rankin Scale (mRS) used to assess the disability level in patients who have suffered a stroke or other neurological condition. It measures the degree of dependence on others for daily activities, with scores ranging from 0 (no symptoms) to 6 (death).
4. The ICH (Intracerebral Hemorrhage) score is a clinical grading scale used to assess the severity of intracerebral hemorrhage in neurology. It is used to predict the risk of mortality and functional impairment in patients with intracerebral hemorrhage.
5. The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is a system used in neurology to classify ischemic strokes based on their etiology or underlying cause. It was developed to aid in the selection of appropriate treatment strategies for patients with ischemic stroke.
6. The CHA2DS2-VASc score is a clinical scoring system used in neurology and cardiology to assess the risk of stroke in patients with atrial fibrillation (AF). AF is a heart rhythm disorder that increases the risk of stroke due to blood clots forming in the heart and traveling to the brain.
7. The HAS-BLED score is a clinical scoring system used in neurology and cardiology to assess the risk of bleeding in patients with atrial fibrillation (AF) who are receiving anticoagulant therapy.
8. The TICI (Thrombolysis in Cerebral Infarction) score is a grading system used to assess the success of a mechanical thrombectomy procedure in patients with acute ischemic stroke.

Resources for the Shelf Exam

Alright, now for what you’re really here for! Our general approach to prepare for the Neurology Clerkship was to start studying for the Shelf Exam right away, which allowed us to have the content knowledge we needed not just to answer questions on the rotation, but also to apply that knowledge, ground it in experience, and then really understand clinical scenarios that appeared on the Shelf Exam.

UWorld
It’s hard to be better prepared for a Shelf Exam than to crush the UWorld question bank for that subject area. We certainly recommend getting through all the Neurology questions over the weeks leading up to your shelf. No matter the rotation, it’s always a challenge to find time to complete questions during clerkships, but try to knock out 20, 10, even 5 at a time if you can, whether before arriving at the hospital, during a lunch break, or before heading to bed.

Something Ben started doing during his Neurology Clerkship to get through questions when the motivation was slim was to use tutor mode. It creates a sense of low-stakes engagement with the questions, and it allowed him to start questions no matter how much time he had at that moment. In tutor mode, once you answer a question and see the result, either you get it right and want to answer another question, or you get it wrong and definitely want to answer another questions to avoid ending your question set with an incorrect.

cheesydorian Anki deck

There are currently 492 cards in the neurology cheesydorian Anki Deck. This deck is perfect for people who love Anki and will give you the high yield topics when it comes to the anatomy, pathology, and physiology. We were surprised with this deck, because in multiple blocks, it included topics that we didn’t see on any other resource or NBME self-assessment, but that did appear on Shelf Exams.

NBME Self Assessments

These are really good, and we recommend taking every NBME self-assessment in preparation for the Shelf Exams. These give you questions that are most like what you'll see on the real exam as the question writers are the same. You'll start to see some patterns between the questions that they ask that you can pick up on and hone in.

Rotation Ready App

Of course, we wish we had the rotation ready app when we were going through our Neurology Clerkships. The goal of this app is to prepare students for all those pimping questions Attendings and Fellows love to throw your way. Honestly, we found there were more questions on our Neurology Clerkships than on others, but that they were also easier to answer correctly with the right preparation.