Clinical Neurology in General Practice

Dr. Owen Powell

Fforestfach Medical Centre

Aims

• To be able to diagnose and manage common neurological presentations in General Practice

• To be aware of Guidelines on best practice

• To be aware of local resources and care pathways

Case 1

• Donna, a 24 year old secretary is brought to surgery by her mother. Her mother thinks she may have had a fit the day before. She says that she was watching TV and suddenly started shaking for 1 -2 minutes. This has never happened before and she is normally well.

What aspects do you need to know in the history?

What investigations should you arrange?

What is your diagnosis and management plan and how do you explain this to Donna?

Resources

Differentiating factors

Differential diagnosis

Risk of recurrence

NICE: http://www.nice.org.uk/Guidance/CG20/Guidance/pdf/English

Patient information: Epilepsy action; http://www.epilepsy.org.uk/

http://www.epilepsyandpregnancy.co.uk

DVLA : http://www.dvla.gov.uk/media/pdf/medical/aagv1.pdf

• Differentiating seizure from syncope: helpful and unhelpful featuresUnhelpful features—often mistakenly thought to indicate seizure but can occur in syncope

• Twitching and jerking

• Incontinence (reflects a full bladder at the time of the event)

• Pallor

• Bitten tip of tongue

• Fatigue after the event

• Helpful features—indicate a seizure

• Confusion after the event lasting >2 minutes

• Deeply bitten lateral border of the tongue

• Tonic then clonic movement lasting >1 minute

• Deep cyanosis

• Reported risk factors for seizure recurrence • Remote symptomatic aetiology (pre-existing static brain abnormalities that

are, by implication, causative)

• Focal neurological findings

• Focal seizure phenomenology (including Todd's paresis)

• Focal or generalised epileptiform activity on EEG

• Tumours or other progressive lesions as the underlying pathology

• Status epilepticus

• Family history of epilepsy

• Previous febrile seizures

• Mr. Palmer is a 56 year old pharmacist who complains of tiredness and pain in his right shoulder. Work is becoming difficult. His wife has said he is slow doing everything.

He has a past history of vertigo and hypertension

Medication-lisinopril 5mg daily

What else do you want to know from the history?

How would you examine this man?

What is your management plan and explanation?

Resources

• Parkinson’s Treatment Centre, Gorseinon

• NICE:CG35 Parkinson's disease full guideline.mht

• Patient and doctor information: Parkinson's Disease Society - Resources for GPs.mht

• Sarah, a 25 year old teacher, complains of headaches. She describes a pain on the right side of her head, mostly around the eye. The pain is severe and makes her feel sick or vomit. She has had three of these headaches in the last 6 weeks. She is worried she may have a brain tumour.

• What important factors do you need to elicit from the history?

• What examination would you perform?• What is your management plan?

Resources

• Bandolier: IHS criteria for migraine

• British Association for the Study of Headache: Diagnosis and Management of Headache