Pediatric Neurology for Pediatric Residents

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					           Pediatric Neurology for Pediatric Residents

                                     CONTENTS

I     Pediatric Inpatient Team

II    Pediatric Neurology Elective

III   Learning Goals and Objectives

IV    Resident Assessment

V     Recommended Reading and Resources
                        I - PEDIATRIC NEUROLOGY INPATIENT TEAM

Introduction
Rounds
Pediatric Conferences and Didactics

                                     INTRODUCTION

Purpose
The goals of a pediatric neurology inpatient team include:
      1. Improved care and coordination of pediatric neurology patients
      2. Increase pediatric neurology knowledge base for pediatric residents
      3. Encourage pediatric resident interest in pediatric neurology
      4. Support pediatric resident involvement in the care of pediatric neurology
           patients
      5. Provide a coordinated effort on the behalf of the Pediatric and Neurology
           departments in reaching the above stated goals

Team model
The Pediatric Inpatient team model will include:
      1. Pediatric ward resident (PWR) from the Grey Team
               a. One familiar with the patients on the pediatric neurology consult
                  service. If possible, an upper level resident and intern should attend.
      2. Neurology resident rotating on the pediatric neurology
               a. Team leader, unless there is a pediatric neurology resident rotating on
                  service
      3. Medical student (if rotating on the service)
      4. Pediatric Neurology resident when on service
      5. Pediatric Neurology Attending

                                       ROUNDS

         Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Legarda, 0900-   0900-    0900-     0830-  0900-     See     See
Santos,  0930    0930     0930      0930    0930   below    below
Zecavati                          extended
                                   rounds



Rounds:
Daily walk rounds will be held from 9 to 9:30am. Prior to that, consult rounds will be
done by the Adult Neurology/Pediatric residents on service from 8:30 to 9am, or as
designated by the pediatric neurology attending. In the event that the pediatric neurology
attending is unable to attend rounds at 9am, the PWR resident will round with the
Pediatric team leader (Adult/Pediatric Neurology resident). In the case that the Pediatric
Neurology attending is not at 9am rounds, he or she will be available by phone during
that time for questions regarding more acute care needs.

On weekends, the attending will see and write progress notes on the child neuro service
patients. He/She will also communicate the "plan" to the covering pediatric resident.
The pediatric resident will be responsible for the progress notes on these days and should
pre-round on child neuro service patients. If the pediatric resident is unable to attend
rounds, then the patient can be staffed by phone. Pre-rounding and notes will still be
required.

Extended Rounds:
Extended Rounds will be held at least every other week. This may include an 830AM
Child Neurology case presentation of a current inpatient.

Location:
All team members will meet following Pediatric AM Report, 2PHC.


          PEDIATRIC INPATIENT CONFERENCES AND DIDACTICS

AM Report
Pediatric AM Report will be attended at least every other week by the rotating Pediatric
Neurology Attending. This will be an inpatient case based conference at 830am on
Thursdays. The PWR resident is expected to attend AM report as per Pediatrics.

Chairman Rounds
Pediatric resident will contact pediatric neurology attending for involvement. Scheduled
dates will appear on the Pediatric Neurology monthly calendar.

Pediatric and Neurology Grand Rounds
Pediatric residents and staff will be invited to all Neurology Grand Rounds (Thursday 8-
9am) when the topic is Pediatric Neurology. Similarly, Neurology residents and staff
will be invited to all Pediatric Grand Rounds (Friday 8-9am) when the topic is Pediatric
Neurology.

Combined Pediatric and Neurology Noon Conferences
Pediatric and Neurology resident lectures will be the 3rd Thursday of each month from
12 to 1pm in the DNCR. Topics as per schedule. TBA.


Didactics
A topic will be discussed weekly during the Thursday extended rounds. This will be
prepared by one of the pediatric neurology inpatient team members. Format is expected
to be informal.
                            II - PEDIATRIC NEUROLOGY ELECTIVE
                                  IN/OUTPATIENT EXPERIENCE

Introduction
Inpatient Responsibilities
Outpatient Responsibilities


                                     INTRODUCTION
Purpose
The goals of a pediatric neurology outpatient elective include:
      1. Broaden pediatric neurology knowledge base - inpatient and outpatient
      2. Exposure to common outpatient pediatric neurology problems
      3. Improve ability to perform a pediatric neurology exam
      4. Increase comfort level managing common pediatric neurology complaints
      5. Understand which patients require referrals to Pediatric Neurology


                                INPATIENT RESPONSIBILITIES

Inpatient Team
Part of the Pediatric Inpatient team
        See Inpatient team for details pertaining to rounding and lectures
Responsibilities
        1. Round with inpatient team
        2. Consults when needed
               a. Pediatric Resident on elective is the primary contact person for
                    consults.
               b. Continue to follow patient on team
               c. Progress notes
        3. Communication
               a. Help improve communication with pediatric inpatient team
               b. Facilitates ordering of pediatric EEGs and EMU transfers


                              OUTPATIENT RESPONSIBILITES

Outpatient Experience
Primary focus of this rotation is the outpatient experience
       1. Clinic Schedule
              a. If not following an inpatient consult, then attend Pediatric Neuro
                   clinic. If following an inpatient consult, round with team and then
                   report to clinic.
              b. See monthly Pediatric Neurology Calendar for Clinic Schedule
                        i. Lists attending, location, and times for all Pediatric Neurology
                           clinics
   2. Clinic Responsibilities
          a. New Patients
                  i. Perform history and general physical exam
                 ii. Review prior records and studies
                iii. Neurology exam
                         1. Shadow, then perform with attending, then perform
                             independently
                                 a. Pre and post-rotation neuro exam check list
                iv. Present patient and discuss differential diagnosis, assessment,
                     and plan
                         1. Include summary statement with pertinent neurological
                             exam findings
                 v. Dictate or type letter to referring physician
                         1. Route to pediatric neurology attending
          b. Established Patients
                  i. Obtain Interval History
                         1. verify medications
                         2. review labs and studies
                 ii. Exam, presentation, and notes as above for "New Patients"



               III - LEARNING GOALS AND OBJECTIVES

               Pediatric Neurology for the Pediatric Residents
                          Inpatient and Outpatient

A. Perform a neurological history, examination, and developmental evaluation of
   children of all ages.

       a. View and study this web site on the neurologic examination up to age 2 ½:
          http://medstat.med.utah.edu/pedineurologicexam/home_exam.html
       b. See the attached “Summary of the Neurologic Exam”
       c. See the attached “cheat sheet” of developmental milestones

B. Understand and employ the concept of anatomical localization of neurologic
   symptoms and deficits.

       a. Differentiate between upper motor neuron (UMN) and lower motor
          neuron (LMN) dysfunction by using the distribution of strength, muscle
          bulk, muscle tone, fasciculations, sensory changes, reflex change
               i. List components of the motor unit
              ii. Differentiate tone from strength
             iii. Define spasticity
       b. Differentiate between UMN and LMN facial weakness
       c. Differentiate sensory disorders secondary from peripheral nervous system
          lesions ( radiculopathy, mononeuropathy, brachial plexopathy) versus
          from central lesions (recognize cortical sensory loss, spinal sensory level)
       d. During the evaluation of the comatose patient, define and localize:
               i. Decorticate vs decerebrate posturing
              ii. Pupillary abnormalities (e.g. pinpoint, “blown” pupil)
             iii. Vestibuloocular reflexes (“Dolls eyes”)
             iv. Discuss how these findings help determine structural vs metabolic
                  cause, bihemispheric vs brainstem lesions
              v. Know herniation syndromes

C. Demonstrate knowledge of cardinal manifestations of neurologic disease

       a. Many of the below learning objectives are addressed by the “Pedi Neuro
          Board Review”
       b. Core neurology topics will be discussed in conferences and didactics.

       c. Seizures
               i. Distinguish seizures from non-epileptic events e.g. jitteriness,
                  breath-holding spells, night terrors, gastroesophageal reflux,
                  neonatal sleep myoclonus, pseudoseizures
              ii. Describe the evaluation and management of new-onset seizure, and
                  understand epidemiological basis of decision-making (i.e. risk
                  factors for recurrence)
             iii. Plan the initial therapy for status epilepticus
             iv. Know the medications that can be administered rectally to treat
                  status epilepticus
              v. Know the possible etiologies of status epilepticus: infection, toxin,
                  electrolyte imbalance, drug withdrawal
             vi. Plan the initial therapy for neonatal seizures
            vii. Discuss the possible etiologies and evaluation of neonatal seizures
           viii. Be aware of common side effects of antiseizure medications,
                  including Phenobarbital, phenytoin, valproic acid, lamotrigine,
                  topiramate
             ix. Be aware of treatment options for refractory epilepsy
              x. Discuss evaluation and management of febrile seizures
             xi. Know the risk factors associated with febrile seizures related to
                  later epilepsy
            xii. Recognize the epilepsy syndrome of benign rolandic epilepsy
                  (“benign epilepsy with centrotemporal spikes”)
           xiii. Recognize the epilepsy syndrome of absence epilepsy, its
                  differential diagnosis, evaluation, and treatment
           xiv. Be able to differentiate absence and complex partial seizures
            xv. Recognize the characteristic clinical picture of infantile spasms
           xvi. Know the natural history and prognosis of infantile spasms: risk of
                  developmental delay/regression and later epilepsy
     xvii. Recognize the epilepsy syndrome of juvenile myoclonic epilepsy
    xviii. Recognize Lennox-Gastaut syndrome

c. Headache
       i. Know the clinical characteristics of tension-type and migraine
          headaches
      ii. Discuss abortive and prophylactic management of migraine
          headaches
     iii. Know the elements of history that characterize a headache due to
          increased intracranial pressure and other signs/symptoms of
          increased ICP
     iv. Know the signs and symptoms of a headache that indicate a need
          for follow-up with magnetic resonance imaging or CT scan

d. Altered Consciousness/Trauma
        i. Define lethargy, coma
       ii. Diagnose brain death in children and the persistent vegetative state
      iii. Recognize clinical characteristics of “non-accidental trauma” or
           “shaken baby syndrome” and discuss evaluation and differential
           diagnosis (e.g. bleeding diathesis, osteogenesis imperfecta, glutaric
           aciduria-I)
      iv. Know the role of pharmacologic therapy in acute spinal cord or
           craniocerebral trauma

e. Infectious or Post-Infectious Neurologic Disorders
         i. Know the presenting signs, symptoms, and differential diagnosis of
            Guillain-Barre syndrome
        ii. Know the complications of Guillain-Barre syndrome
      iii. Know the possible presentations (e.g. optic neuritis, transverse
            myelitis) and differential diagnosis of ADEM (acute disseminated
            encephalomyelitis)
       iv. Know the presenting signs, symptoms, and differential diagnosis of
            cerebellitis (i.e. other causes of acute cerebellar ataxia and vertigo)
        v. Discuss the causes and presentation of congenital intrauterine
            infections (TORCH), including herpes and its time of presentation
            and mode of transmission
       vi. Know the 3 most frequent organisms in neonatal meningitis
      vii. Know the epidemiology, presentation, evaluation, and treatment of
            meningoencephalitis. Recognize the CSF findings in herpes
            encephalitis
     viii. Recognize the CSF findings in bacterial (including Lyme) and
            viral meningitis. Know the complications of bacterial meningitis.
       ix. Know that most abscesses contain multiple organisms, including
            anaerobes
        x. Know that neuroimaging studies should be done before
            examination of the CSF in suspected brain abscesses
       xi. Know the presentation, evaluation, and treatment of infant
           botulism
      xii. Know the presentation of Sydenham’s chorea, as well as
           relationship to diagnosis of rheumatic fever, and treatment

f. Genetic/Metabolic Syndromes
       i. Recognize the historical features indicative of a degenerative CNS
          disorder
      ii. Know the typical presentations and diagnosis of Wilson’s disease
          and Menkes’ disease
     iii. Recognize the potential infectious presentation of galactosemia
     iv. Recognize the common presentation of a urea cycle defect
      v. Recognize the common presentation and evaluation of a
          leukodystrophy
     vi. Recognize the presentation and mode of transmission of
          mitochondrial disorders (e.g. Kearns-Sayre, MERRF, MELAS)
    vii. Know the clinical manifestations and diagnosis of Rett syndrome

g. Movement Disorders
       i. Know the definition, types, and evaluation of cerebral palsy
      ii. Know the presentation of kernicterus
     iii. Differentiate between tics and epileptic seizures; know when to
          treat tics; understand the diagnostic criteria for Tourette syndrome
     iv. Recognize opsoclonus-myoclonus and discuss possible etiology
          and evaluation

h. Neuromuscular Disorders
       i. Know the differential diagnosis of weakness and an increased
          serum creatine kinase concentration
      ii. Know the laboratory studies available to diagnose muscle disease
          of childhood
     iii. Know the presentation, diagnosis, and mode of transmission of
          Duchenne muscular dystrophy
     iv. Know the presentation, diagnosis, and treatment of
          dermatomyositis
      v. Recognize the presentation and diagnosis of myotonic dystrophy
     vi. Recognize the symptoms, signs, and evaluation of myasthenia
          gravis

i. Neurodevelopment
       i. Identify primitive reflexes and know age of onset and
          disappearance
      ii. Understand the definition/purpose of an individualized educational
          program (IEP)
     iii. Know the diagnostic criteria for attention deficit/hyperactivity
          disorder
      iv. Be aware of the current consensus regarding evaluation of global
          developmental delay

j. Malformations
       i. Identify the clinical manifestations and plan the diagnostic
          evaluation of spinal dysraphism; know the various types and
          potential complications
      ii. Discuss the presentation of Arnold-Chiari Type I and association
          with headache
     iii. Discuss types of cerebral malformations, including cortical
          dysplasias (e.g. lissencephaly), Dandy-Walker malformation, and
          complications
     iv. Know diagnosis and further evaluation of septo-optic dysplasia
      v. Know diagnosis of fetal alcohol syndrome

k. Neurocutaneous Disorders
       i. Know the clinical characteristics of tuberous sclerosis
      ii. Know the clinical characteristics of neurofibromatosis type I and
          potential complications, including neoplasms
     iii. Know the clinical characteristics and complications of Sturge-
          Weber

l. Miscellaneous
       i. Recognize complications of ventriculoperitoneal shunts
      ii. Be aware that brain and spinal cord tumors are the 2nd most
          common group of neoplasms in children (1st leukemia) and know
          the usual location in children (infratentorial)
     iii. Identify the clinical features of childhood stroke including
          sinovenous thrombosis
     iv. Recognize the signs and symptoms of and plan treatment for Bell
          palsy
      v. Know the clinical difference between papilledema and optic
          neuritis (papillitis)
                     Goals Based on Core Competency Teaching

I.     PATIENT CARE

1.     Interview patients more skillfully.
2.     Examine patients more skillfully.
3.     Improve neurological localization skills.
4.     Accurately diagnose pediatric neurological disorders requiring inpatient
       admission.
5.     Effectively manage the patient with acute neurological illness including
       appropriate drug therapy and non-pharmacologic treatments.
6.     Define and prioritize pediatric patients' neurological and medical problems.
7.     Appropriately select and interpret pertinent laboratory and imaging studies.
8.     Improve technical skills like performing lumbar puncture
9.     Effectively implement long-term medical care of the pediatric neurology patient.
10.    Improve clinical ability to anticipate, prevent, and treat neurological
       complications of medical and surgical conditions.
11.    Improve efficiency of care in the hospital setting.


II.    MEDICAL KNOWLEDGE

1.     Improve basic neurological knowledge base.
2.     Expand clinical knowledge base regarding common pediatric neurologic problems
       requiring inpatient admission. This includes but not limited to AIDP, myasthenia
       gravis and exacerbation, multiple sclerosis exacerbation, acute seizures and status
       epilepticus, status migrainosus, meningitis/encephalitis, and stroke in children.
3.     Improve understanding of evaluation and diagnostic testing for common pediatric
       neurologic illness.
4.     Expand knowledge of potential interventions to anticipate and prevent future
       complications relative to the patient's illness.
5.     Assess and critically evaluate current medical information and scientific evidence
       relevant to patient illness.


III.   PRACTICE-BASED LEARNING AND IMPROVEMENT

1.     Identify and acknowledge gaps in personal knowledge and skills in the care of
       hospitalized patients with pediatric neurological illness.
2.     Develop and implement strategies for filling in gaps in knowledge and skills.


IV.    INTERPERSONAL SKILLS AND COMMUNICATION

1.     Communicate effectively with patients and families
2.    Communicate effectively with physician colleagues at all levels, especially
      regarding effective written communications.
3.    Communicate effectively with all ancillary care personnel involved in the care of
      the patient to ensure comprehensive and timely care.
4.    Present patient information concisely and clearly, verbally and in writing.
5.    Teach colleagues and medical students effectively.


V.    PROFESSIONALISM

1.    Demonstrate respect, compassion and integrity when dealing with patients and
      families.
2.    Demonstrate sensitivity and respect for patients' age, culture, race, gender and
      religious beliefs.
3.    Demonstrate a commitment to ethical principles of providing or withholding care,
      patient confidentiality and informed consent, and business practices.
4.    Demonstrate a commitment to carrying out professional duties including
      punctuality, reliability, chart maintenance and independent learning and
      professional development.
5.    Demonstrate professional respects for superiors, colleagues, students and all
      members of the health care team.

VI.   SYSTEMS-BASED PRACTICE

1.    Understand and utilize the multidisciplinary resources necessary to care optimally
      for patients in the outpatient setting.
2.    Collaborate with other members of the health care team to assure comprehensive
      patient care.
3.    Use evidence-based, cost-conscious strategies in the care of outpatients.

4.    Understand the long-term consequence of patient care in relation to the
      individual's socioeconomic status.
                       IV.     PEDIATRIC RESIDENT ASSESSMENT

   1. Neurology Exam Checklist
         a. Pre and Post Rotation Exam Assessment
                                                                                      YES    NO

Notation of pertinent general exam findings                                           ____   ____
        E.g. HC, dysmorphic features, anterior fontanelle, flattening of occiput, cardiac
        abnormalities, hepatosplenomegaly, cutaneous lesions

Notation of Mental Status                                                             ____   ____
        E.g. Orientation, alertness, language, detailed MS exam if pertinent

Cranial Nerves                                                                        ____   ____
        II: funduscopic exam, visual fields, visual acuity, blink reflex
        III, IV, VI: conjugate movements, strabismus, extraocular movements, ptosis
        V: sensation, corneal reflex
        VII: facial strength
        VIII: hearing, nystagmus
        IX/X: palate elevation, gag
        XI/XII: sternocleidomastoid strength, tongue

Motor                                                                                 ____   ____
        Bulk
        Tone (e.g. traction response, horizontal/vertical suspension, limb tone)
        Strength
        Motor development if pertinent

Gait                                                                                  ____   ____
        E.g. weight-bearing, toe, heel, tandem walking, Romberg sign

Coordination                                                                          ____   ____
        E.g. dysmetria on reaching for toys, FNF or HKS, rapid alternating movements

Reflexes                                                                              ____   ____
        I.e. DTRs, primitive reflexes e.g. Moro, Tonic neck, Propping, Parachute

Sensory                                                                               ____   ____
        E.g. cries with, localizes, purposefully withdrawals to stim; spinal level;
        Dorsal column modalities (vibration, proprioception), LT, temperature

Exam Observed by Attending _________________________ (signature)

Suggestions/Areas to Focus On ___________________________________
    2. Core Competency Teaching and Evaluation for Pediatric Resident rotating
       on Pediatric Neurology Inpatient Team or Pediatric Neurology Elective

Competency             Educational Activity             Evaluation/Assessment/Feedback
1. Patient Care        Clinical teaching rounds         Neurological Exam Checklist
                       Outpatient Clinic                Monthly rotation evaluations
                       Multi-disciplinary rounds        Verbal feedback
                       Conferences and Didactics
                       Subspecialty AM Report
                       Curriculum
2. Medical Knowledge   Clinical teaching rounds         Monthly rotation evaluations
                       Outpatient clinic                Verbal feedback
                       Noon conferences
                       Grand Rounds
                       Case Presentation
                       Literature searches
                       Self study
3. Practice-Based      Clinical teaching rounds         Monthly rotation evaluations
Learning and           Outpatient clinic                Verbal Feedback
Development            Case-related conferences:        Written feedback for presentation
                       AM report
                       Chairman rounds
                       Case-presentation
4. Interpersonal and   Clinical teaching rounds         Monthly rotation evaluations
Communication Skills   Outpatient clinic                Verbal feedback
                       Interactions with students,
                       residents, and ancillary staff
                       Case presentations
                       Effectiveness of charting and
                       clinical notes
                       Curriculum
5. Professionalism     Clinical teaching rounds         Monthly rotation evaluations
                       Outpatient clinic                Verbal feedback
                       Interactions with patients,
                       families, students, residents,
                       faculty, and ancillary staff
                       Timely completion of medical
                       records
                       Attendance for rounds, AM
                       report, conferences
                       Curriculum
6. Systems-based       Clinical teaching rounds         Monthly rotation evaluations
Practice               Outpatient clinic                Verbal feedback
                       Multi-disciplinary rounds and
                       team meetings
                       Clinical conferences
                       Curriculum
           V - RECOMMENDED READING AND RESOURCES

1) Obtain a copy of Clinical Pediatric Neurology, Fenichel. Topics to review prior
   to inpatient or outpatient rotation:
       a. Neurologic abnormalities of the newborn
       b. Ataxia of childhood
       c. Movement disorders
       d. Coma
       e. Headache
       f. Seizures

2) Basic articles, “cheat-sheets” and summary tables, as well as several classic
   background papers.

3) Excellent websites include:
      a. www.neuro.wustl.edu/neuromuscular (specifics of essentially all
          neuromuscular symptoms/signs/disorders)
      b. www.ncbi.nlm.nih.gov/Omim (search for neurogenetic disorders based on
          signs or symptoms)
      c. www.genetests.org (listings of genetic testing and facilities that perform
          them for neurogenetic disorders, also links to reviews of those disorders)
      d. http://medstat.med.utah.edu/pedineurologicexam/home_exam.html
          (videos of a pediatric neurologist examining children up to age 2 ½)

4) Pre and post rotation - pediatric neuro exam

5) Textbook References:

   Fenichel, Gerald. Clinical pediatric neurology A signs and symptoms approach.
   Swaiman, Kenneth. Pediatric neurology Principles and practice.
   Zitelli, Basia. Atlas of Pediatric Diagnosis (Neurology Chapter).

6) Contact Numbers:
   Cesar C. Santos, MD
   Chief, Division of Pediatric Neurology
   Pager: 5-2804
CONTENTS OF LEARNING MATERIALS

  1) “SUMMARY of the Neurologic Exam”

  2) SUMMARY of how to differentiate upper motor neuron and lower motor neuron
     lesions

  3) Cheat-sheet of developmental milestones

  4) Summary of Seizure Types and Medications

  5) Status Epilepticus Algorithm

  6) Seizures
        a. Friedman MJ. Seizures in Children. Pediatr Clin N Am 2006, 53:257-77.
        b. Olson, D. Paroxysmal Events. Differentiating Epileptic Seizures from
            Nonepileptic Spells. Consultant for Pediatricians 2008; 461-69.
        c. Zupanc ML. Neonatal seizures. Pediatr Clin N Am 2004; 51:961-978.
        d. Breningstall GN. Breath-holding spells. Pediatr Neurol 1996;14:91-97.
        e. Hirtz D et al. Practice parameter: Evaluating a first nonfebrile seizure in
            children. Neurol 2000;55:616-623.
        f. Hirtz D et al. Practice parameter: Treatment of the child with a first
            unprovoked seizure. Neurol 2003;60:166-175.
        g. Tables and summaries: Antiseizure medications by seizure type, AEDs
            dosing and side effects, Diastat dosing
        h. Algorithm - Status Epilepticus
        i. Jarrar RG and Buchhalter JR. Therapeutics in pediatric epilepsy, part 1:
            the new antiepileptic drugs and the ketogenic diet. Mayo Clin Proc
            2003;78:359-370.
        j. Buchhalter JR and Jarrar RG. Therapeutics in ped epilepsy, part 2:
            epilepsy surgery and vagus nerve stimulation. Mayo Clin Proc
            2003;78:371-378.
        k. Hirtz DG. Febrile seizures. Pediatr Rev 1997;18:5-8.
        l. Practice Parameter: the neurodiagnostic evaluation of the child with a first
            simple febrile seizure. Pediatr 1996;97:769-772.
        m. Baumann RJ and Duffner PK. Treatment of children with simple febrile
            seizures: the AAP practice parameter. Pediatr Neurol 2000;23:11-17.
        n. Summary of status epilepticus treatment protocol
        o. Holmes GL and Riviello JJ. Midazolam and Pentobarital for Refractory
            Status Epilepticus. Pediatr Neurol 1999;20:259-264.
        p. Riveiello, J et al. Practice Parameter: Diagnostic assessment of a child
            with status epilepticus. Neurology 2006; 67: 1542-1550.
        q. Hrachovy, R Infantile Epileptic Encephalopathy with Hypsarrhythmia
            (Infantile Spasms/West Syndrome). J Clin Neurophys 2003; 20(6):408-
            425.
7) Headache, Alteration of Consciousness
      a. Hershey, A, et al. Headaches. Curr Opin Pediatr. 2007; 19: 663-669.
      b. Lewis, DW, et al. Practice parameter: Evaluation of children and
         adolescents with recurrent headaches. Neurol 2002; 59: 490-498.
      c. Lewis, DW, et al. Practice parameter: Pharmacological treatment of
         migraine headache in children and adolescents. Neurol 2004; 63:2215-
         2224.
      d. Practice parameter: The management of concussion in sports. Neurol
         1997;48:581-585.
      e. Chapter on Coma and its causes.
      f. Schneider S and Ashwal S. Determination of brain death in infants and
         children. Swaiman K ed, Pediatric neurology Principles and practice.

8) Infectious or Post-Infectious Neurologic Disorders
       a. Evans OB and Vedanarayanan V. Guillain-Barre syndrome. Pediatr Rev
           1997;18:10-16.
       b. Jones CT. Childhood autoimmune neurologic diseases of the central
           nervous system. Neurol Clin 2003;4:
       c. Chapter on Ataxia
       d. Wubbel L and McCracken GH. Management of bacterial meningitis:1998.
           Pediatr Rev 1998;19:78-84.
       e. Bonthius DJ and Karacay B. Meningitis and encephalitis in children: an
           update. Neurol Clin 2002;20:
       f. Fenichel GM. Assessment: neurologic risk of immunization: report of the
           therapeutics and technology assessment subcommittee of the American
           Academy of Neurology. Neurol 1999;52:1546-1552.

9) Genetic and Metabolic Syndromes
      a. Dagli, A, Zori, R, Heese, B. Testing Strategy for Inborn Errors of
          Metabolism in the Neonate. Neoreviews 2008; 9(7):e291-298.
      b. Chapter on Psychomotor Retardation and Regression.

10) Movement Disorders
      a. Wolf, D, Singer H. Pediatric movement disorders: an update. Curr Opin
         Neruol 2008:491-496.
      b. Dooley, J. Tic Disorders in Childhood. Semin Pediatr Neurol 2006; 13:
         321-242.

11) Neuromuscular Disorders
       a. Bodensteiner, J. The Evaluation of the Hypotonic Infant. Semin Pediatr
          Neurol 2008; 15:10-20..
       b. Chapters of Floppy Infant Syndrome causes and Flaccid Limb Weakness
          in Childhood.
       c. Algorithm for Hypotonia and Weakness
       d. Table Etiology of Infantile Hypotonia.
   12) Neurodevelopment
          a. Shevell M et al. Practice parameter: evaluation of child with global
             developmental delay. Neurol 2003;60:367-380.
          b. Palmer FB and Capute AJ . Pediatr Rev 1994;15:473-479.
          c. Taft LT. Cerebral palsy. Pediatr Rev 1995;16:411-418
          d. Summary, Practice parameter: Diagnostic Assessment of a Child with
             Cerebral Palsy.
          e. Johnson C, Myers, S. Identification and Evaluation of Children with
             Autism Spectrum Disorders. Pediatrics 2007; 120(5): 1183-1215.

   13) Malformations
          a. Chapter on Disorders of Cranial Volume and Shape.

   14) Neurocutaneous Disorders
          a. Dahan, D, Fenichel, G, El-Said, R. Neurocutaneous Syndromes. Adolesc
             Med 2002;13(3): 495-509.

   15) Stroke
           a. Rivkin MJ and Volpe JJ. Strokes in children. Pediatr Rev 1996;17:265-
              277.
           b. Table. Suggested diagnostic laboratory evaluation in children who have
              arterial ischemic stroke.
           c. Seidman, C, Kirkham, F, Pavlakis, S. Pediatric Stroke. Curr Opin Pediatr
              2007, 19: 657-662.

   16) Hypoxic Ischemic Encephalopathy
          a. Roland, E and Hill, A. Clinical Aspects of Perinatal Hypoxic-Ischemic
             Brain Injury. Semin Pediatr Neur 1995: 2(1); 57-71.
          b. Abend, N and Licht, D. Predicting outcome in children with hypoxic
             ischemic encephalopathy. Pediatr Crit Care Med 2008: 9(1); 32-39.

   17) Brain Tumors
          a. Partap, S and Fisher, P. Updated on new treatments in childhood brain
              tumors. Curr Opin Pediatr 2007: 19: 670-674.
          b. Pollack IF. Brain tumors in children. New Eng J Med 1994;331:1500-
              1506.

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