Inpatient Adult

Objectives

  • Students will contribute to the care of those admitted for a variety of acute and serious neurological problems.
  • Students will divide their time between General Neurology and Stroke Services to gain broad exposure.
  • Typical diseases will often include ischemic stroke, hemorrhage, infection, seizure, encephalopathy, intractable neurological pain, inflammatory neuropathy, and demyelinating disease.

Service Overview

  • Stroke and General Neurology are two separate services located on 11400/11500.
  • An Attending and Chief Resident leads each service, with 4 junior residents. Thus, the entire inpatient adult service consists of two attendings, two chiefs, and eight residents.
  • Call every 4th night. Two residents on-call per evening, one each from Stroke and General Neurology.
  • Residents leave post-call after their patients are presented – typically ~10:30am.
  • Daily admits will be distributed as “shorts” to the post-post-call team and the pre-call team. Patients go to the overnight call person beginning at 5pm, but may start earlier if the slots for daily admissions fill.
  • New patients come from the emergency department, transfers from outside hospitals, direct admissions from home or clinic, transfers from the NeuroICU, or transfers from other services in BJH.
  • Patients admitted to the ward service will be presented to the attending and chief typically the next morning. Patients can also be admitted to a faculty member’s own service, with patient coverage by a nurse practitioner or resident.
  • When your resident leaves for the day, those patients are “signed-out” to the on-call person. When a resident returns the next day, they check with the on-call person for any events.
  • A master list of patients with updated active problems and to-do list is kept on the computer. You should obtain this list to help stay pro-active and engaged on rounds.
  • You should always have patients to follow. Begin to assume care for several patients on day 1.

Team Teaching Rounds

  • Key time to learn about patient care, observe the neurology history and physical, present patients, and interact with the team and attending.
  • Stay on rounds while new patients are being presented. Students should typically be excused from rounds when the post-call team leaves ~10:30am.
  • Rounds typically (check with your resident) start in the 11400 conference room at 7:30 AM on M/Tu, 8:15 AM on W/Th, 9:15AM Friday if there is Grand Rounds or 7:30 AM Friday if no Grand Rounds.
  • Remain engaged and attentive. At bedside, try to get close to attending and patient to see exam findings.
  • Patient presentations should be concise, pertinent, prepared, and no longer than 5-10 minutes.
    • Always start with neurological problem-based chief complaint.
    • DO NOT READ FROM YOUR NOTE. Prepare an index card with a brief outline of the salient aspects of their history and exam.
    • ROS and FH are usually not important for a focused presentation
    • General medical exam should be abbreviated in your presentation (ie. ‘General exam was normal. Notably, there was no…
    • The neurologic exam should also be abbreviated where appropriate (i.e. mental status and cranial nerves were normal).
    • Your assessment should include localization, a prioritized differential, and a plan for investigation and treatment.

Pre-Rounds

  • Key time to get updated on all aspects and progress for your patients.
  • You must pre-round on all your patients, even if you have conference before rounds.
    • Check with your resident or the post-call resident for any interim events.
    • Review vital signs, blood sugars, and notes from nursing, PT/OT/Speech, Social Work/Case Management.
    • Check the computer for labs, test results, and finalized radiology reports.
    • See the patient for a pertinent history and exam.
    • Check with nurse for any events or concerns.
    • Review the chart for event notes, consultant recommendations, and changes in orders or medications. Check medicine list to see if anything was withheld.
    • Check telemetry for events.

After Rounds

  • Finish your SOAP note and update with the most accurate information.
  • Review daily orders for your patients.
  • Prioritize and complete tasks on your patients.
  • Work-up or pick-up new patients.

Admissions

  • Aim for 1 patient on regular day, 1-2 patients on long admission day.
  • Maintain a census of 3-5 patients at all times.
  • Work with everyone on your team to admit patients.
  • Latest to get new patient is 4:00 pm on regular admission day, 7:30 pm on a long admission day.
  • Seek new patients as soon as available from your resident.
  • Work-up patient and page resident to discuss after collecting your thoughts.
  • Incorporate resident discussion into note and upcoming presentation.
  • Read about patient’s diagnoses and solidify your assessment and plan.
  • Create outline for patient presentation.