mcq's for gp's
TRANSCRIPT
Neurology String of Pearls
The department
Quiz
Cases from a clinic
What you need to know about Epilepsy: Alan Whone and Sue Higgins
What you need to know about PD: Mark Silva and Ann Gilbert
What you need to know about MS: Roswell Martin and Richard Warner
The Department4 Consultants (Fuller, Silva, Martin, Morrish), 1 Reg, 1 SHO4 Specialist nurses (2 MS, 1 Epilepsy, 1 PD)2 GP assistants Secretaries at GRH and CGHOP’s every day except Wednesday in CGH and GRH Neurology beds at GRHErmin House (neuro disability unit) at GRHNeurophysiology at GRHSpecial interests: Silva, Morrish: PD, Movement Disorders, Fuller: EpilepsyMartin: White matter disease, CADASIL
What do we do?
Clinics (new and special interest)
Ward cover – inpatients (approx 10-16) and referrals (3 -4 per day)
Supervising nurse specialists, junior medical staff
Paperwork
Teaching
Research
Other interests
Referrals Received
0
50
100
150
200
250
300
350
400
450
Other 106 118 126 120 98 76 112 98 72 97 95 117 88 100 99 75 89 94 93 96 73 113 74 109
GP referred 255 229 237 248 246 237 218 252 191 215 234 238 243 281 241 243 232 235 266 242 166 245 210 244
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
Feb-06
Mar-06
Apr-06
May-06
Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Total of referrals 3951 (06-07). No significant change over preceding year. 72% from GP’s.
3477 new attendances: 5802 follow-ups
Neurology
100
200
300
400
500
600
Num
bers
wai
ting
as a
t en
d of
mon
th
13+ wks 9-13 wks 5-8 wks 0-4 wks 2005/06 total
0-4 wks 197 239 244 209 220 191 211 229 212 162 205 197 204
5-8 wks 120 125 147 148 119 154 103 102 118 136 84 100 70
9-13 wks 29 42 53 42 50 56 58 40 44 43 40 16 5
13+ wks
2005/06 total 432 491 513 520 529 560 540 456 444 402 360 398 346
previous yr end
Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar
Waiting list
800 GP referrals (70% of total)1 Consultant1 GP assistantPopulation served 520,000
2848 GP referrals per year (72% of total)4 Consultants2 GP assistants3 nurse specialistsPopulation served 585,000
1984
2006
How things change……..
From “Workload of an English Neurologist” DL Stevens*
*other observations: GP’s managing bulk of neurology. Referrals rising, will it plateau?
Neurology Out-Patients: What do we actually do?
Geraint Fuller 2006
Gloucestershire Royal Hospital
Initiatives affecting neurology
New appointments: Maximum waiting lists
NICE guidelines MS, Epilepsy, PD
NSFFollow up appointments:
Limitations of the Study
Reflects local practice Local consultants Local GPs Local Population
Diagnoses are presentation diagnoses and not final diagnoses
12 week study
Results
Doctors Nurses
Doctors and Nurses
New 587 43 630
New/old 74 56 130
Follow up 1058 273 1331
Total 2091
new:old ratio 1.6 2.8 1.8
New Patients by Diagnosis
Epilepsy
Migraine
Headaches
Movement disorders otherthan Parkinson's disease
Dizziness and giddiness
Stroke and TIA
Peripheral neuropathies
MS
Faints and blackouts
Cranial nerve disease
Peripheral nerve palsies
This series Stevens Wiles UK
Disorders of consciousness 17.1 17.3 17.7 17.6
Headaches, migraine and face pain 22.8 15.5 18.0 18.8
Movement disorders 8.1 7.1 3.5 2.7
Nerve, root syndromes and neuropathies 11.0 11.2 12.7 13.0
MS 3.9 6.1 10.0 5.9
Stroke and TIA 4.8 6.5 3.0 10.3
Cranial nerve syndromes 3.1 7.1 3.8 2.3
Dizziness 5.3 3.2 5.0 2.7
Sub-total of these diagnostic categories 76.1 74.0 73.7 73.3
New Patients
What did we do?
010
2030
4050
6070
8090
100
New Follow up Nurses
Review
Examination
Tests
Explainresults/Diagnosis
What did we do?
0
10
20
30
40
50
60
70
New Old Nurses
Start medication
Review medication
Change medication
Arrange othertreatment
New and New/old
New and discharge
New, investigateanticipate dischargeInvestigation cycle
Chronic: review tillresolvedChronic: intermittentFUChronic: long term FU
Previous studies
This study See and discharge 38%; investigate/anticipate
discharge 22%; investigation cycle 21%; chronic disease 16%.
ABN survey (1993): 69% discharged; 29% followed up; 10% admitted
Wiles (1996) 38% discharged; 34% discharged with investigations;
23% investigated or admitted Hopkins (1985)
33% discharged; 49% expected to be seen once more; 18% seen on continuing basis
Follow up diagnoses (%)
Epilepsy 37.3
MS 16.6
Parkinson’s disease 9.6
Focal dystonia 3.5
Other movement disorders 3.5
Headaches 3.2
subtotal 73.7
Over view of Out-patients
Chronic diseases
Part of investigation cycle
Anticipate discharge
See and discharge
DNA and discharge
DNA and further appontmentDNA and furtherappontment
DNA andfurtherappontment
Chronic diseases
New 1 2 3 4 5 to 8 9 or more
644 253 150 106 96 182 415Total =1,846
0
20
40
60
80
100%
Type of Patient
Number of Prior Appointments
Conclusions
Neurology OPD provides 2 intertwined services Consultation service for new symptoms Chronic disease management service
Consultation service
For patients with headaches, migraine, giddiness and dizziness, strokes and TIAs, faints and blackouts, focal peripheral neuropathies, cervical and lumbosacral disease, cranial nerve disorders.
Most seen once, few seen up to 4 times.Service capacity determined by incidence
of these conditions
Chronic Disease Service
Predominantly for patients with Epilepsy, MS and Movement disorders. Significant number of patients with rarer diseases.
Half patients may be discharged if problem resolves
Half long term follow up Service capacity determined by
prevalence of these conditions
Two Services
Consultation service 68% of doctors time
Chronic disease management 32% of doctors time 100% of nurses time
To whom to refer what?
NeurologyElderly care
Acute Medicine
Eg: Parkinson’s, Weak legs, Dizzy turns, TIA
ENT
Radiology
Neurophysiology
Medical Genetics
Does it matter? Variables include urgency, personnel, geography, experience
Opthalmology
How we think:
Where is the lesion? What is the lesion? What can we do about it?
1. A 78 year old left handed man has suddenly lost his ability to express speech and attends urgently. What neurological signs might you look for/expect?
a. L homonymous hemianopia?
b. R LMN facial weakness?
c. R triceps weakness?
d. Constructional apraxia?
e. R plantar extensor?
A warm-up quiz
There are no other signs.
How would you classify this event and what is the prognosis?
PACI TACI LACI POCI
The Major Stroke Syndromes
TACI = Total anterior circulation infarct
PACI = Partial anterior circulation infarct
POCI = Posterior circulation infarct
LACI = Lacunar infarct
Arterial Territories
Anterior Cerebral
Posterior Cerebral
Middle Cerebral
Anterior Circulation
Posterior Circulation
Total Anterior Circulation (TACI)
Hemiplegia contralateral to the lesionHemianopia contralateral to the lesionHigher cortical dysfunction eg dysphasia, dyspraxia
CT MRI
Partial Anterior Circulation (PACI)
Isolated higher cortical dysfunction ORAny 2 of hemiparesis, higher cortical dysfunction & hemianopia
CT MRI
Posterior Circulation (POCI)
Isolated hemianopia OR Brainstem syndrome
CT MRI
Lacunar Infarct (LACI)
Pure motor stroke OR Pure sensory stroke OR
Sensorimotor stroke
By occlusion of single deep perforating artery
CT MRI
Prognostic Value30 Day Outcome
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TACI PACI POCI LACI
Dead
Dependent
Independent
It resolves in two hours. What do you do?
Admit (?where) Refer to TIA clinic (?how) Manage at home
ABCD score (risk of CVA in 48 hours)
Age >60 1
BP>/=140/90 1
Unilateral weakness 2
Speech impaired, no weakness 1
Duration>1 hour 2
Duration 10 mins to 1 hour 1
Diabetes 1
Score 6-7: 8.1%Score 4-5:4.1%Score 3 or below:1.0%
You decide to manage at home. What tests are urgent?
FBC U&E ECG CXR CT head U/S carotids Echocardiogram
NNT – How many to treat to prevent 1 stroke per year?
Warfarin if patient in AF Carotid surgery if >70% in symptomatic side Aspirin Statin (whatever the lipids) Stopping smoking
Intervention NNT
Warfarin in AF 12
Carotid surgery in >70% stenosis 6
Aspirin 100
Statin 20
Smoking 43
2. A 37 yr old lady presents with : R arm and R leg feel weak and odd, left leg feels numb, buzzing in neck on flexion; all coming on over 1 week. On examination she has:Normal cranial nerves and visual fields, UMN weakness in R arm and leg. R plantar goes up, Impaired JPS in R arm and R leg Impaired pinprick in L arm and L leg
What is the name of the syndrome? What is the buzzing? Where is the lesion? Give three possible diagnoses
Possible causes (B-S and Lhermitte’s)
Disc Demyelination Other SOL eg tumour, abscess B12 deficiency
Useful things to know 1:
Corticospinal tract
In brain on opposite side
In cord on the same side as arm/leg
Starts in the motor cortex,Runs through internal capsule,Crosses in the medulla
Brain
Spine
Useful things 2: Dorsal-columns
Vibratory and joint position sense. Their sensory neurones run on the same side of spinal cord and cross over in midbrain
(ie like motor nerves)
Brain
Spine
Useful things 3: Spino-thalamic
Convey pain and temperature
Sensory neurones cross to the opposite side of spinal cord soon after entering.
Brain
Spine
Useful things 4:The Visual Fields
“Homonymous” field defect = lesion behind the optic chiasm
“Monocular” defect = lesion in front of chiasm
3. A 36 year old lady is referred to you by optician (from routine eye test)
What is it called? What abnormalities of vision might you look for? Give three causes
4. A patient known to have PD (for 5 years) is brought in by his wife; she is complaining of his fidgety movements. What would you do/say?
Blood tests (which?) Stop tablets and reassess after 1 week Is he bothered? Add Pimozide/tetrabenazine/haloperidol Refer to whom?
5. A 27 year old man blacks out whilst walking from the toilet on an aeroplane. When he wakes (a few minutes later) the cabin crew tell him he has had a fit and that he needs to seek urgent medical attention. What things might help you work out what happened and what to do next?
What do you do next?
Tell him he mustn’t drive (till when?) Refer him for specialist opinion (which?) Request urgent EEG and CT Check ECG Tell him to avoid aeroplanes, lunch and toilets
6. A 24 year old girl with epilepsy for ten years wants to start a family and stop her medication. Give 5 things that she (and you) might want to discuss.
GP letter to neurology
“This girl wants to start a family. Please see and do the needful”
7. A 24 year old lady with one previous episode of optic neuritis and otherwise well has developed urinary frequency and urgency. What might you do?
Some suggestions
MSU Start oxybutinin Refer to urology for catheter Refer to MS nurse Treat suspected relapse with steroids (which?) Measure urinary residual Consider disease modifying treatment Pregnancy test MRI Head MRI Spine
What might we do?
1. Do same as usual in non-MS patient
ie MSU, ?pregnant
2. Add MS implications
Is diagnosis secure? Maybe re-investigate
Consider steroids if disabling relapse
Measure urinary residual ?SIC
Consider disease modifying treatment
8. A 36 year old man attends surgery 5 days after developing a headache during sex. What does he need?
Routine referral to neurology Urgent referral to neurology Urgent admission to AAU CT scan Lumbar puncture MRI/MRA A full history (what do you want to know?) Examination for meningism
Screening for aneurysm
Best test is angiography (1% risk) MRI/MRA less good- may show false pos/neg If positive, risk of neurosurgery/coiling 2-3% What is the risk of leaving an incidental aneurysm? Usually only screen if 2 first degree relatives, or PC kidneys
9. A 37 year old tax adviser is worried that her memory is failing her. What do you do?
Reassure : dementia unlikely in 37 year old Refer to neurology Blood tests (which) Test her memory (how?) Take a history (what do you want to know?) Examine her (what for?)
Some causes of dementia in the young
Alzheimer (usually familial) SOL New Variant CJD Untreated Complex Partial Seizures Myxoedema HIV
11. A 25 year old lady with recurrent headache has read (in the Daily Mail) that having her PFO sealed will cure her headache. What do you do?
Refer to cardiology for “starflex” closure Take history (what do you want to know?) Examine (what do you look for?) Prescribe analgesia (?which)
12. A 42 year old man attends with his wife. His sister died three months ago of a brain haemorrhage, he has headaches and he wants a scan. His BP is 160/100, he smokes 20/day and drinks 40 units per week. What do you do?
Direct request for CT Refer for urgent neuro opinion re headache and screening Reassure, and reassess in 1 month Counsel in respect of fags and beer Request urgent admission for ?SAH
Some Clinic Cases