Neurology in Primary Care

Overview

Lecture reviews primary care assessment, diagnosis, and first-line management of common neurological conditions. Emphasis on red flags, focused exams, guideline-based care, and appropriate referrals.

Objectives

• Recognize clinical presentations and neurological red flags.
• Perform focused neurological and cranial nerve examinations.
• Implement guideline-based interventions for common conditions.
• Know when to refer to neurology, ENT, ophthalmology, or stroke centers.

Low Back Pain: Assessment and Management

• History: onset, duration, radiation, trauma, neurologic deficits.
• Exam: gait, motor strength, sensory, reflexes, straight leg raise.
• Red flags: cauda equina, progressive deficits, infection, cancer, major trauma.
• Imaging: reserved for red flags; otherwise not indicated initially.
• First-line management: NSAIDs, physical therapy, activity modification, education.
• Documentation: record sensory exam and straight leg raise technique.

Bell’s Palsy

• Presentation: acute unilateral facial paralysis involving upper and lower face.
• Pathophysiology: peripheral cranial nerve VII involvement.
• Differentiate from stroke: stroke typically spares the forehead.
• Treatment: steroids within 72 hours; eye lubrication or taping at night.
• Antivirals: for severe cases; often prescribed with steroids.
• Referral: ENT or neurology for atypical cases or no improvement.
• Ramsay Hunt syndrome: reactivation of varicella zoster in cranial nerve VII near ear; urgent ophthalmology if suspected.

Concussion

• Initial management: relative physical and cognitive rest 24–48 hours.
• Symptom control: short-term analgesics, hydration, sleep optimization.
• Protocols: structured return to play and return to learn.
• Red flags: worsening neurologic symptoms, repeated vomiting, seizures, deteriorating consciousness; urgent referral.

Cranial Nerve Assessment

• Test flow: smell, vision, extraocular movements, facial strength, hearing, gag reflex, shoulder shrug, tongue movements.
• Skill: practice for speed, accuracy, and smooth sequence.

Delirium: Diagnosis and Management

• Definition: acute fluctuating change in attention and cognition; common in older adults.
• Causes: infection, medications, metabolic issues, hypoxia; identify and treat.
• First-line management: orientation, sleep hygiene, hydration, mobility, sensory aids.
• Antipsychotics: only for severe agitation with safety concerns.

CAM (Confusion Assessment Method)

• Purpose: evidence-based tool to detect delirium and distinguish from dementia.
• Features assessed: acute onset and fluctuation; inattention; disorganized thinking; altered level of consciousness.
• Diagnostic rule: acute onset/fluctuation and inattention plus either disorganized thinking or altered consciousness.

Delirium vs Dementia vs Stroke

• Onset: delirium sudden; dementia gradual; stroke very sudden.
• Course: delirium fluctuating and reversible; dementia progressive; stroke with sudden deficits.
• Clinical clues: delirium with acute illness or new meds; dementia with gradual functional impact; stroke with focal deficits.
• Screening tools: CAM for delirium; Mini-COG or MMSE for dementia; FAST exam for stroke.

Headache Assessment and Red Flags

• History: onset, duration, pattern, triggers, medications, red flags.
• Exam: vitals, neurological assessment, fundoscopic exam, neck evaluation.
• Red flag framework: SNOOP4 guides imaging or urgent referral.
• Primary headaches: often managed in primary care when no red flags.

SNOOP4 Criteria for Headache Red Flags

• Systemic symptoms.
• Neurologic signs.
• Onset sudden.
• Older age.
• Pattern change.

Migraine: Diagnosis and Treatment

• Diagnosis: ICHD-3; recurrent unilateral pulsating pain with photophobia, phonophobia, nausea; ± aura.
• Acute treatment: NSAIDs, triptans, antiemetics, newer agents if triptans contraindicated.
• Prevention: beta blockers, topiramate, amitriptyline, CGRP inhibitors for frequent or refractory cases.
• Monitoring: headache diary for frequency, triggers, response.

Multiple Sclerosis (MS)

• Consider MS: young adults with optic neuritis, transverse myelitis, diplopia, sensory changes.
• Diagnosis: MRI brain and spine with contrast; lesions disseminated in time and space.
• Referral: neurology for confirmation and disease-modifying therapy initiation.

Acute Herniated Disc (Radiculopathy)

• Presentation: radicular leg pain, dermatomal numbness, positive straight leg raise.
• Red flags: cauda equina, progressive weakness, systemic symptoms; urgent imaging.
• Management: NSAIDs, activity modification, physical therapy; surgery for severe or refractory cases.

Seizure Disorders in Primary Care

• Acute seizure: ensure safety, airway and vitals; benzodiazepines if seizure >5 minutes and available; activate EMS.
• Chronic management: start anti-seizure medication after two unprovoked seizures or high-risk first seizure.
• Collaboration: coordinate closely with neurology for selection and refractory cases.

Stroke Pharmacology in Primary Care

• Acute ischemic stroke: rapid assessment for thrombolytic eligibility; IV alteplase if appropriate.
• Secondary prevention: antiplatelet for non-cardioembolic stroke; anticoagulation for atrial fibrillation; high-intensity statins; blood pressure control; lifestyle changes.
• Referral: rapid transfer to stroke center when stroke suspected.

Validated Tools and Protocols

• CAM: delirium detection and differentiation.
• SNOOP4: headache red flag criteria guiding imaging and referral.
• FAST: stroke recognition in acute settings.
• Return-to-play: structured stages after concussion under clinician supervision.

Case Summaries

• Low back pain with L5 sensory loss: no red flags; conservative care; monitor for cauda equina or progressive deficits.
• Bell’s palsy vs stroke: forehead involvement suggests peripheral VII; steroids early; protect eye; consider antivirals; refer if atypical; ophthalmology if zoster suspected.
• Concussion in athlete: rest 24–48 hours; symptom management; structured return to play; urgent evaluation for red flags.
• Frequent migraine with aura: acute NSAIDs, triptans, antiemetics; consider preventive beta blocker, topiramate, amitriptyline, CGRP inhibitors; use headache diary.
• Suspected MS after transient vision loss and paresthesia: MRI brain and spine with contrast; CSF oligoclonal bands support; refer to neurology for DMT.
• Acute sciatica after lifting: image only with red flags; conservative management first; surgery for severe persistent pain or deficits.
• First unprovoked seizure: ensure safety, airway; benzodiazepine if seizure >5 minutes; initiate medication after second seizure or high-risk first; involve neurology.
• Acute stroke presentation: within 90 minutes; IV alteplase if eligible; secondary prevention includes antiplatelet, statin, BP control, anticoagulation for atrial fibrillation; urgent stroke center referral.
• Delirium in hospitalized older adult: diagnose with CAM; treat infection, meds, metabolic causes; reorientation, hydration, sleep; antipsychotics only for unsafe agitation.

Key Terms & Definitions

• Cauda equina syndrome: compression causing saddle anesthesia, bowel/bladder dysfunction, weakness; emergency.
• Ramsay Hunt syndrome: varicella zoster reactivation affecting facial nerve; facial paralysis with ear involvement.
• CAM: tool assessing acute onset, inattention, disorganized thinking, altered consciousness.
• SNOOP4: mnemonic for headache red flags.
• ICHD-3: international criteria for headache disorders classification.
• CGRP inhibitors: preventive migraine medications targeting calcitonin gene-related peptide.
• Disease-modifying therapy: medications that reduce MS relapses and slow progression.

Action Items / Next Steps

• Practice cranial nerve examination until fluent and efficient.
• Use CAM for suspected delirium and document features clearly.
• Apply SNOOP4 to headache presentations to guide imaging and referrals.
• Educate back pain patients on conservative care and red flag monitoring.
• Initiate early steroids for Bell’s palsy and implement eye protection.
• Follow structured return-to-play and return-to-learn after concussion.
• Maintain vigilance for MS in young adults with visual or sensory episodes.
• Coordinate with neurology for seizures and MS; with ENT and ophthalmology when indicated.

Structured Summary Table