6. Neurology

6. Neurology
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6. Neurology

By Andrew Harris
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Hi Everyone,

Take your shoes off for a minute. Can you feel the soft fluffy carpet under your feet? Or the cool smooth tiles? Or the grain of he floor boards? When was the last time you walked through the grass with bare feet? Taking these times to nourish your tactile senses is really enjoyable and calming. If you’ve had a bad day, just take a few minutes to give it a go.

This article is about Neurology.

One of the most common forms of neurological complaints I’ve seen is the good ole “sciatica”. A patient will present with burning pain radiating from their buttock down their leg. This is always a very distressing and debilitating pain for patients. I know my Grandfather had this pain and it literally floored him for several weeks – he would just lie on the lounge room floor in a beanbag with his favourite Labrador by his side.  The factors that determine urgency of assessment are all the red flags of back pain – fever, saddle parasthesia, IV drug use, etc. If these aren’t present, then it’s not recommended to do imaging for the first 4-6 weeks as this condition can typically resolve with simple analgesia. If imaging is required, then MRI is the investigation of choice. Having a good arsenal of pain relief options for the patient is also helpful!

I once had a patient present for a whooping cough vaccine. His grand-daughter was soon to be born and his wife sent him in for the vaccination. He was 45 years old and hadn’t been to the doctor for anything more than a sprained ankle in the last 20 years. I took the opportunity to invite him back for a 45-49 year old health assessment (707). As part of this assessment I noted an irregular pulse, and ECG confirmed atrial fibrillation. This started a journey of investigation and management with the hope of reducing his risk of cerebrovascular accident – all by taking the time to reach over and feel his pulse. Never underestimate the value of reaching across the space between you and your patient.

If a patient reports a “funny turn” don’t forget to complete a complete neurological assessment. I had a patient come to see me to follow up on some results of a CT brain ordered by another GP. The patient originally presented after feeling a bit off after a “funny turn” the previous day. The other GP ordered a CT brain out of thoroughness, but failed to complete a neurological examination. The CT returned showing that the patient had indeed had a stroke, and further examination revealed a very clear homonymous hemianopia. A well practiced cranial nerve examination can be quick and simple.

Be kind to yourself, and nourish your tactile sensations.

Dr Andrew Harris
Director of Amadeus Education.

Did you know?

According to BEACH data, 4.2% of all encounters in General Practice were specifically related to the neurological system. Consider this as you are preparing for your exams. (Source: General practice activity in Australia: 2015-16. https://bit.ly/2c4d8Em)

Presenting complaints:

These are the common presenting complaints that should be covered for this topic:

Common conditions:

These are the common conditions that should be reviewed for this topic:

Topics

Important reading

Headache – including migraine, tension, cervicogenic, cluster, subarachnoid haemorrhage.

– Management of chronic headache. AFP, March 2014. (https://bit.ly/2U5H2cl)
– Childhood headache and H. pylori: A possible association. AFP, March 2013. (https://bit.ly/2Va8TYC)
– Headache Clinical Practice Guidelines. RCH. (https://bit.ly/2DZ28SE)

Cerebrovascular disease – including stroke, TIA

– Clinical guidelines for stroke management 2007. Stroke Foundation. (https://bit.ly/2u2LA73)
– TIAs: Management in general practice. AFP, November 2010. (https://bit.ly/2Iq5Cmw)
– Transient ischaemic attacks: Assessment and management. AFP, November 2010. (https://bit.ly/2SbLG6N)
– Visual field defects after stroke: A practical guide for GPs. AFP, July 2010. (https://bit.ly/2twbBME)

Multiple sclerosis

– Multiple sclerosis. AFP, December 2011. (https://bit.ly/2XfcruH)
– Multiple sclerosis: Diagnosis, management and prognosis. AFP, December 2011. (https://bit.ly/2ElcrSw)
– Multiple sclerosis presenting with homonymous hemianopia. AFP, October 2009. (https://bit.ly/2DZwzIx)
– Optic neuritis: More than a loss of vision. AFP, October 2009. (https://bit.ly/2E1kbrf)

Peripheral neuropathy

– Paresthesia and peripheral neuropathy. AFP, March 2015. (https://bit.ly/2NgoxPz)
– Neuropathic pain: A management update. AFP, March 2013. (https://bit.ly/2Sg5Dcx)
– Back pain with lower limb paresis: A case study. AFP, October 2012. (https://bit.ly/2Xeof07)

Epilepsy

– Epilepsy in adults. AFP, March 2014. (https://bit.ly/2BOwyXv)
– Epilepsy in pregnancy: A collaborative team effort for obstetricians, neurologist and primary physicians for a successful outcome. AFP, March 2014. (https://bit.ly/2DTzOks)

Tremor – including Parkinson’s disease, Huntington’s disease

– My hands shake: Classification and treatment of tremor. AFP, September 2009. (https://bit.ly/2SMvAFP)

Bell’s palsy

– Acute unilateral facial nerve palsy. AFP, May 2011. (https://bit.ly/2V9bRNm)
– A general practice approach to Bell’s palsy. AFP, November 2016. (https://bit.ly/2SePHar)

Restless leg syndrome

– Restless legs syndrome. AFP, May 2009. (https://bit.ly/2U9Wu6N)

Head injury

– Head Injury Clinical Practice Guidelines. RCH. (https://bit.ly/2GVfwdO)
– Traumatic brain injury – support for injured people and their carers. AFP, November 2014. (https://bit.ly/2XnXQgG)
– Traumatic brain injury: Long term care of patients in general practice. AFP, December 2011. (https://bit.ly/2XgsYOQ)
– Updated guidelines for the management of sports-related concussion in general practice. AFP, March 2014. (https://bit.ly/2NfLYbQ)
– Minor head injuries in children: An approach to management. AFP, May 2010. (https://bit.ly/2EkKtpM)
– Sports related concussion management in general practice. AFP, January/February 2010. (https://bit.ly/2XfpCMj)

Motor neuron disease

– Motor neuron disease: Caring for the patient in general practice. AFP, December 2011. (https://bit.ly/2BJMQB8)

Guillain Barre syndrome

– Rehabilitation in Guillain Barre syndrome. AFP, December 2004. (https://bit.ly/2T4wAo2)

Myelopathy including polymyositis,  dermatomyositis, muscular dystrophy

– Skin rash associated with limb weakness. AFP, October 2012. (https://bit.ly/2tEOJut)
– Duchenne muscular dystrophy (DMD) – information for carriers. RCH. (https://bit.ly/2ElNd6n)

Carpal tunnel syndrome

– Carpal tunnel syndrome: Can it be a work related condition? AFP, September 2009. (https://bit.ly/2GPBm2d)
– Nerve conduction studies. AFP, September 2011. (https://bit.ly/2V9WC6F)

Medication doses:

These are the medications and doses that should be learned for the exam:

Condition

Medication

Migraine

  • Acute:

    • Aspirin soluble 900mg PO stat

    • Ibuprofen 400mg PO stat

    • Rizatriptan 10mg PO stat. If symptoms recur, then repeat dose. Must wait 2 hours between doses.

    • Metoclopramide 10mg TDS as needed for nausea

  • Prophylaxis:

  • Amitriptyline 10mg PO nocte.

  • Pizotifen 0.5mg PO nocte

Trigeminal neuralgia

  • Carbamazepine 100mg BD

Neuropathic pain

  • Amitriptyline 10-25mg PO nocte, increasing to maximum of 75-100mg nocte

Mnemonics:

These are some important mnemonics relevant to this topic:

CHECKS:

Here are the list of recommended Checks that would be useful in your study for GP exams (accessed via subscription from http://gplearning.racgp.org.au):

  • Neurology, August 2018
  • Dizziness, July 2011
  • Pain management, November 2011
  • Fitness to drive, January 2012
  • Neurology, August 2013
  • Head pain, August 2014

Focus on clinical skills:

Here is a brief focus on some OSCE preparation topics related to this topic:

  • Parkinson’s disease assessment
  • Glasgow coma scale
  • Gait assessment
  • Dermatome/myotomes
  • Neurological examination playlist by GP Synergy: https://bit.ly/2Dhn0VW

Focus on medicolegal:

Here is a brief focus on the medicolegal issues covered in Australian Family Physician:

Copyright © 2021 Andrew Harris

2 thoughts on “6. Neurology”

  1. i like the medication doses section, as an OTD , hard to know what is in favoue as a first line treatment , this section helps to clarify 🙂 thank you Anrew

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