How to present on neurology rounds
Neurology presentations turn on one question: where is the lesion? Your attending wants the exam in the same order every time, precise enough to localize from, and the localization said out loud before you name a cause. For a stroke, two numbers come first: the last known well time and the NIHSS.
- Target
- 3 to 5 minutes on inpatient rounds, under a minute in a stroke alert
- Lead with
- Where the lesion is, then what it is
Here is the format inpatient and stroke teams expect, a word-for-word example from a fictional stroke admission, and the questions that come up on the service.
What your attending listens for
Neurology attendings want localization first: where the lesion is and which findings put it there. Give the exam in the same order every time, and for a possible stroke, last known well and the NIHSS.
The structure
Step 1: One-liner with tempo
Age, sex, handedness, risk factors, and the deficit with its tempo: sudden suggests stroke or seizure, days to weeks inflammation, infection or a mass, months degeneration.
Step 2: History and overnight
For stroke, last known well to the minute and any thrombolysis or thrombectomy. How the deficit evolved, antithrombotics, and on follow-up, overnight neuro checks.
Step 3: The exam, in a fixed order
Blood pressure and glucose; for stroke, the NIHSS and what scored. Then mental status, cranial nerves, motor (0 to 5 by muscle), sensation, reflexes (0 to 4+) and plantar responses, coordination, gait.
Step 4: Imaging and studies
What the CT, CTA or MRI shows and where, then telemetry, echo, EEG or lumbar puncture.
Step 5: Localization, then the cause
The level (cortex, subcortex, brainstem, cord, root, nerve, neuromuscular junction or muscle) and the findings that put it there, then the likely cause and the differential.
Step 6: Plan
Acute treatment, remaining workup, secondary prevention, a swallow screen before anything by mouth after a stroke, therapies, disposition.
A word-for-word example
Step 1: One-liner with tempo
Ms. Rivera is a 71-year-old right-handed woman with hypertension and type 2 diabetes, admitted for sudden aphasia and right arm weakness treated with tenecteplase.
Step 2: History and overnight
Last known well was 5:10 p.m. yesterday; at 5:40 her husband found her unable to get words out, dropping things from her right hand. No anticoagulant. Tenecteplase at 6:35, 85 minutes after last known well. Neuro checks stable overnight.
Step 3: The exam, in a fixed order
Blood pressure 152/84, glucose 164. NIHSS 3, down from 7: 1 each for aphasia, facial droop and arm drift. Alert, nonfluent, with poor naming and intact comprehension. Right lower facial droop sparing the forehead. Right arm drift with 4 out of 5 triceps and finger extensors; legs full strength. Sensation intact. Reflexes 2+ and symmetric, right toe upgoing. No ataxia; gait deferred.
Step 4: Imaging and studies
CT showed no hemorrhage; CTA, no large vessel occlusion or carotid stenosis. A1c 7.6%, LDL 138. Sinus rhythm on telemetry; MRI and echo pending.
Step 5: Localization, then the cause
Nonfluent aphasia with right face and arm weakness sparing the leg, and an upgoing toe, localizes to the left frontal lobe, superior division of the left MCA. A cortical stroke without large vessel disease suggests an embolus, so we are looking for atrial fibrillation.
Step 6: Plan
If her 24-hour scan at 6:35 tonight shows no hemorrhage, we start aspirin. Atorvastatin 80 milligrams today, blood pressure under 180/105 until then, and telemetry, with a 30-day monitor if no atrial fibrillation shows up. She passed her swallow screen; speech, PT and OT today.
Ward pearls
- Report last known well, not when symptoms were found. For a deficit found on waking, it is the last time anyone saw the patient normal.
- Grade strength by muscle (0 to 5) and reflexes (0 to 4+), with plantar responses. "Weak on the right" localizes nothing.
- In Guillain-Barré syndrome or myasthenic crisis, report the vital capacity and negative inspiratory force; oxygen saturation falls late.
Classic pimp questions
- Upper versus lower motor neuron signs, and where each puts the lesion
- Stroke syndromes by artery (MCA, ACA, PCA) and the lacunar syndromes
- Thrombolysis within 4.5 hours and its contraindications; who gets thrombectomy, up to 24 hours
- Status epilepticus: a benzodiazepine at 5 minutes, then levetiracetam, fosphenytoin or valproate
Not sure how to field them? How to take the questions
Practice it out loud
A script you have read is not one you can say. Present a fictional patient to an AI attending who cuts in, asks why, and grades you on a rubric, then drills whatever you missed.
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Other rotations
Educational content with fictional patients, not medical advice. Teams and institutions differ: follow your attending, your institution's protocols and current guidelines.