DEPARTMENT OF PEDIATRICS



DEPARTMENT OF PEDIATRICS

WALTER REED ARMY AND NATIONAL NAVAL MEDICAL CENTERS

NATIONAL CAPITAL CONSORTIUM PEDIATRIC RESIDENCY PROGRAM

November 2006

CHILD NEUROLOGY ROTATION

Duration of Rotation: 4 weeks

Eligibility:

a. Pediatric Residents (PL-2, PL-3)

Positions Available: 1-2 per block

Facilities Used: Child and Adolescent Neurology Clinic, Neurodevelopmental Clinic (with developmental pediatrics and psychiatry), Pediatric Ward, NICU, PICU, Clinical Neurophysiology Service (EEG, EMG)

Teaching Staff: Marleigh Erickson MD, Michael Mitchell MD, Stephen Sharp, MD

Child neurology fellows

GENERAL OBJECTIVES

The Child Neurology rotation is intended to familiarize residents with the evaluation and management of children with neurologic problems. Common problems evaluated and discussed will include (but not be limited to) seizures (febrile and non-febrile), headache and migraine, paroxysmal events, increased intracranial pressure, developmental delay, mental retardation, hypotonia, macrocephaly, microcephaly, autism, movement disorders, neurocutaneous disorders, ataxia, metabolic disorders, developmental brain malformations, cerebral palsy and indwelling devices (ie. Vagal nerve stimulator, Baclofen pump)

COMPETENCY-BASED GOALS AND OBJECTIVES

1. KNOWLEDGE

• GOAL: Understand how to identify whether a child is neurologically normal or suffers from a neuropathological condition

OBJECTIVES:

a. Identify normal and abnormal neurologic development including gross and fine motor development, speech and language, cognition, and socialization

• GOAL: Understand how to recognize and manage simple neurological conditions often not requiring referral.

OBJECTIVES:

a. Describe and understand the pathophysiology, clinical features, and evaluation of the following conditions:

1. Non-febrile seizures: absence, complex partial, generalized tonic-clonic, common age- dependant epilepsy syndromes

2. Febrile seizures

3. Static encephalopathy/cerebral palsy

4. Migraine and tension headache

5. Mild closed head trauma and simple linear skull fractures

6. Tic disorders

7. Attention deficit disorder

8. Developmental delays

9. Transient neurological disturbances due to drug ingestion

• GOAL: Seizures -- Understand how to evaluate and manage, and when to refer, patients with seizures.

OBJECTIVES:

a. Differentiate the various seizure types (e.g., generalized, simple partial, complex partial, absence, common age-dependant epilepsy syndromes)

b. Understand appropriate first-line anticonvulsant choices based upon the type of seizures, and AED side effect profiles.

c. Discuss the diagnostic evaluation and management of a child with new onset seizure, and the child with breakthrough seizures.

d. Discuss the indications for referral for patients with seizures (e.g., complicated, difficult to diagnose or manage, intractable, status epilepticus)

e. Be familiar with guidelines for evaluation and management of a patient in status epilepticus.

f. Demonstrate an understanding of and counsel parents about febrile simple and complicated seizures, including epidemiology, natural history, risk factors for afebrile seizures, and evaluation and treatment options.

• GOAL: Neurological Pharmacology -- Understand the indications for use, the side effects and the mode of action of commonly used neurological drugs.

OBJECTIVES:

a. For commonly used anticonvulsants: describe indications and contraindications, side effects, and appropriate laboratory tests to follow drug therapy and side effects and drug interactions with common drugs (e.g., Tegretol and erythromycin)

b. For commonly used drugs which can affect the CNS: describe the indications and contraindications, side effects, and appropriate laboratory tests to follow drug therapy and side effects

2. PATIENT CARE

Demonstrate a compassionate, effective, family-oriented, and age appropriate approach toward the evaluation and management of children referred to child neurology.

• GOAL: Normal versus Abnormal Neurology -- Understand how to identify whether a child is normal or suffers from a neuropathological condition.

OBJECTIVES:

a. Demonstrate a skillful neurologic history and exam which can distinguish normal from abnormal findings, peripheral from central nervous system lesions, static from progressive, and localize likely area of neurologic dysfunction.

b. Identify temporary neurological dysfunction (e.g., ataxia or lethargy due to anticonvulsant loading dose) from dysfunction due to pathological conditions (e.g., trauma, poisoning, severe infection, hypoglycemia, electrolyte imbalance).

• GOAL: Common conditions not necessarily requiring neurology referral-- Understand how to recognize and manage neurological disease conditions which may not require referral.

OBJECTIVES:

a. Diagnose and manage the following conditions

1. Febrile seizures

2. Afebrile seizures -- ongoing management of absence, complex partial and generalized tonic-clonic seizures

3. Follow-up for static encephalopathy

4. Migraine and tension headache

5. Mild closed head injury and simple linear skill fractures

6. Transient neurological disturbances due to drug ingestions

7. Tic disorders

8. Attention deficit disorder, uncomplicated

9. Common neurocutaneous syndromes – ongoing surveillance

• GOAL: Conditions generally requiring neurology referral-- Understand how to recognize and initiate management of neurological conditions which generally require referral.

OBJECTIVES:

a. Recognize, provide initial treatment for, and appropriately refer these conditions:

1. Acute encephalopathy (e.g., metabolic, lead, hypertensive, anoxic, drug/toxin induced)

2. Bacterial meningitis

3. Brain tumor

4. Cerebral palsy

5. Coma, increased intracranial pressure

6. Craniosynostosis

7. Encephalitis

8. Headaches which are severe, progressive, or refractory to simple therapy or suggestive of organic pathology (e.g., brain tumor)

9. Hydrocephalus

10 .Movement disorders (e.g., ataxia, chorea, dystonia)

11. Mental retardation, loss of neurologic skills, autism

12. Muscle weakness or flaccidity (e.g., Guillian-Barre, muscular dystrophy, hypotonic)

13. Neurocutaneous syndromes

14. Seizures (which are difficult to diagnose, manage, or are associated with progressive

neurologic impairment or status epilepticus)

15. Severe head trauma, complicated skull fractures, spinal cord injuries

16. Ventriculoperitoneal shunt infections and dysfunction

• GOAL: Seizures-- Understand how to evaluate, manage and refer patients with seizures.

OBJECTIVES:

a. Manage uncomplicated seizures effectively using guidelines and beginning with the appropriate anticonvulsant for the seizure type, and ongoing drug monitoring.

b. Develop an approach for evaluation and management of a patient in status epilepticus

• GOAL: Headaches-- Understand how to evaluate and manage headaches.

OBJECTIVES:

a. Identify the historical features which help differentiate tension, migraine, or chronic daily headache from those caused by increased intracranial pressure.

b. Describe the therapeutic options (abortive and prophylactic) available for migraine and tension headaches in children.

c. Identify the indications for radiologic imaging (CT, MRI) in patients with headaches.

• GOAL: Complex neurological testing-- Understand the indications for neurologic testing which requires complex equipment or procedures.

OBJECTIVES:

a. Describe the indications for and the limitations of the following neurologic tests.

1. Electroencephalogram (EEG)

2. Head computerized tomography scan (CT)

3. Brain magnetic resonance imaging (MRI)

4. Lumbar puncture

5. Psychometric testing

6. Electromyography (EMG) and nerve conduction velocity (NCV)

• GOAL: Prevention-- Understand the pediatricians role in prevention of neurologic disorders in children.

OBJECTIVES:

a. Counsel parents/patients about prevention of head and spinal cord trauma (e.g., seat belts, car seats, helmets, firearm safety, driving injuries))

a. Counsel parents/patients about precautions to be taken in children with epilepsy. Instruct parents on seizure “first-aid” and indications for calling 911.

3. INTERPERSONAL SKILLS AND COMMUNICATION:

-Demonstrate effective communication skills with families and patients referred to the child neurology service.

-Demonstrate effective and collegial communication skills and work effectively with physicians, consultants, nurses, technicians, and administrative personnel.

-Maintain comprehensive and concise written consultations and notes on each patient seen.

-Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills

4. PROFESSIONALISM

-Demonstrate a commitment to patient care and learning by timeliness, responsibility for patients seen on the service, and sensitivity to cultural diversity.

-Demonstrate adherence to ethical principles.

-Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society and the profession, and a commitment to excellence and on-going professional development

-Respond well to constructive criticism and demonstrate a desire for self-improvement

5. PRACTICE-BASED LEARNING AND IMPROVEMENT:

-Demonstrate the ability to use medical literature to effectively and cogently evaluate child neurology conditions or symptoms, and modify management plans appropriately based on the information obtained from the literature.

-Demonstrate receptiveness to feedback provided during the rotation with appropriate modification of behavior to improve performance.

-Use information technology (Ovid, med-line searches, virtual library, etc) to gather medical information and use this in support of their own education.

6. SYSTEMS-BASED PRACTICE:

-Demonstrate understanding of cost issues related to the diagnosis and management of neurological conditions, to include lab tests, radiographic studies, and medications.

-Advocate for patients in the health system.

-Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice.

-Practice cost-effective health care and resource allocation that does not compromise quality of care.

-Be able to access and mobilize resources such as durable medical equipment, pediatric support groups, appropriate consultations and services both within and outside the resident's medical facility.

-Advocate for quality patient care and assist patients in dealing with system complexities

• GOAL: Complex neurological testing--Understand the indications for neurologic testing which requires complex or expensive equipment or procedures.

OBJECTIVES:

a. Describe the indications for the following neurological tests, with respect to information gleaned and relative cost:

1. Electroencephalogram (EEG)

2. Head computerized tomography scan (CT)

3. Head magnetic resonance scan (MR)

4. Lumbar puncture

5. Psychometric testing

6. Electromyography (EMG) and nerve conduction velocity (NCV)

• GOAL: Prevention-- Understand the pediatrician’s role in prevention of neurologic disorders in children.

OBJECTIVES:

a. Advocate for children with neurologic problems and assist families in their attempt to receive services through the Department of Education and local school systems, community 0-3 Programs, and national support groups.

b. Describe how rehabilitation and early intervention can reduce long-term sequelae from neurologic injury or congenital CNS disorders.

Instructional Plan

1. For inpatient and outpatient consults, the resident will be the physician of first contact, and is expected to obtain a complete and relevant history and perform a detailed neurologic examination. The patient will be presented to the attending staff. Abnormal physical findings, differential diagnoses, evaluation and treatment plans will be discussed.

2. Informal discussions covering common child neurology problems will be given by the attending each week. Topics will include: Headaches, Seizures, Non-epileptic spells, Macrocephaly, The floppy infant, Evaluation of the child with developmental delays, Neurocutaneous disorders, Tics and Tourette syndrome., and Status Epilepticus.

Formal presentations of similar child neurology topics are provided on a weekly basis.

3. The EEG procedure will be discussed and classic EEG patterns (partial versus generalized discharges, 3 Hz spike and wave, hypsarrythmia) will be discussed

4. CT scans CT scans and MRI’s will be used to demonstrate common structural, traumatic, and infectious CNS lesions.

5. Teaching files composed of current review articles are available for use during the rotation and may be copied as desired. Suggested textbooks, Clinical Pediatric Neurology by Fenichel or Menkes’ Textbook of Neurology, are also available for study during the rotation.

6. Oral discussions based on neurology and developmental PREP questions and patient

vignettes will be given. These will be based on the above listed topics. Residents will be encouraged to prepare a short lecture/discussion on a relevant neurological topic to be presented to the remaining staff/residents/students.

7. Resident feedback is requested during the rotation so that the rotation can continue to be improved.

Method of Evaluation

The attending will formally evaluate each rotator at the conclusion of this elective. Areas assessed will include the proficiency in evaluating patients with neurologic complaints, performance of a detailed neurologic examination, presentation skills, fund of knowledge, participation during weekly informal lectures, interest and motivation, and performance on oral vignettes.

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