Top tips for GPs
- Tremor: The two most common causes of tremor are essential tremor (ET) and Parkinson’s disease (PD). ET is frequently present for many years before patient seeks medical attention. It is typically symmetrical and present on action such as drinking a cup of tea. Parkinson’s tremor is asymmetrical, frequently present at rest only and typically associated with other motor symptoms such as impairment of fine finger movements. If a further opinion is required please refer to the neurology movement disorder clinic. If the patient is elderly an alternative clinic is the care of the elderly movement disorder clinic.
- Migraine: If there is no diagnostic uncertainty then patients do not necessarily require referral to neurology. If a migraine referral is made it is expected that NICE guidelines have been followed before the referral is made. NICE and BASH offer useful treatment guidelines for management of migraine and headache.
- If a patient greater than 50 presents with a headache it is advisable that inflammatory markers are checked.
- If a patient with previous cancer presents with headache have a low threshold for brain imaging/referral.
- Peripheral neuropathy: Consider checking random glucose, HB1AC, B12, folate. If referral is required please refer to the neurology neuromuscular clinic.
- Cognitive impairment: Patients aged over 70 with cognitive impairment can be referred to the old age psychiatry memory clinic at Longley centre, Northern General Hospital. If younger than 70 then consider referral to the neurology memory clinic. Prior to referral consider checking TFTs, B12 and folate. Consider mood disorders or high alcohol intake as a possible cause especially in the younger patient.
- Epilepsy: if a patient with epilepsy is known to the epilepsy specialist nurses, then advice on their management can be sought by phoning the health professional helpline number (via RHH switchboard).
- First seizure: Refer suspected first seizures to the epilepsy service and do an ECG before referral.
N.B. Patients with seizures caused by alcohol dependence or use of recreational drugs with a well-recognised associated with seizures, such as synthetic cannabis and cocaine should be referred to drug and alcohol services rather than the epilepsy service.
7. Syncope: In cases of loss of consciousness does the patient fulfil the 3Ps? Upright Position/Prodrome (visual clouding, hearing muffled, lightheadedness) /Provoking factors. If yes then the most likely diagnosis is vasovagal syncope and this does not impact the ability to drive. If further opinion is required but the most likely diagnosis is syncope please refer to the Transient Loss of Consciousness (TLOC) clinic via the cardiology department at the Northern General Hospital.
8. Sodium Valproate in women of child bearing age: It is now a requirement that all women of childbearing age (up to age 55) on sodium valproate with epilepsy, be assessed annually by a neurologist with completion of a risk acknowledgement form.
9. SOL found on brain imaging: If brain imaging done in the community has identified a space occupying lesion refer directly to the neuro-oncology MDT for urgent discussion (Sht-tr.Cancer-NeuroOncology@nhs.net Fax: 0114 2268795, Tel: 0114 2268721). These do not need to be referred to the 2 week wait suspicion of brain cancer clinic.
10. Small vessel ischaemia found on brain imaging: Incidental small vessel ischaemia (white matter hyperintensities) is common finding on MR imaging especially in older individuals. The mainstay of treatment is treatment of modifiable risk factors (hypertension, hypercholesterolaemia, smoking and diabetes mellitus) and the promotion of a healthy lifestyle. At present there is no evidence for anti-platelet treatment.
11. Sleep: The Sheffield neurology sleep service is able to see patients who have a sleep disturbance thought to be secondary to a primary neurological disorder (eg parasomnia, narcolepsy). If you suspect that a patient has obstructive sleep apnoea please arrange pulse oximetry or refer to the respiratory service. Psychosocial causes of sleep disturbance are common and at present are not referable to this service. The self help guide ‘Overcoming insomnia and sleep problems’ by Professor Colin Espie is a useful aid.
12. Carpal tunnel Syndrome: If suspicious of carpal tunnel please follow the carpal tunnel management pathway (https://sites.google.com/site/sheffieldccgportal/pathways/carpal-tunnel-clinical-pathway)
Useful Links
2WW suspicion of brain cancer referral form
Sheffield Neurology Outpatient Department Referral Guidance
Epilepsy Specialist Nurse service
Videos
Tremor
This video presented by Dr Fiona McKevitt, Consultant Neurologist and CASES Mentor aims to:
• Show how to assess tremor and in particular distinguish between Essential Tremor (ET) and the tremor of Parkinson’s Disease
• Highlight signs and symptoms that should prompt referral to secondary care
• And, to discuss how ET can be treated in Primary Care