ACADEMY OF FAMILY

PHYSICIANS OF MALAYSIA

POSTGRADUATE DIPLOMA IN
FAMILY MEDICINE

MODULE 9

Neurology and Endocrine Problems

2nd Edition

Author:
Assoc Prof Dr Kwa Siew Kim
MBBS Malaya, DRM, MSc (Lon,) Dip LSHTM
FAFP (Malaysia,) FRACGP (Aust), AMM Malaysia

Family Physician
International Medical University
 Updated on 10th February 2014

Table of Contents Page

7. Total Guided Teaching and Independent Learning

7.1 Problems in Neurology 12
7.2 Endocrine Problems 29

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7 Total Guided Teaching (Reading Tasks) and Independent Learning

7.1 Problems in Neurology

7.1.1 Introduction to Neurological Problems

Since acute neurological problems can continue to be chronic as in stroke management and
rehabilitation, I will not be segregating acute and chronic neurological problems. Such
problems like stroke, epilepsy presenting as fits, etc. will be studied as a continuum. For this
Module, I will include common conditions that are seen by GPs but in between, I will also
include rare but important conditions where early recognition may mean life or death for the
patient and his close contacts. Some conditions like motor neurone disease and multiple
sclerosis are rarely seen in our community but have devastating effects on patient’s life.
Articles on neurology will be given as Reading Tasks or Independent Learning not only to
increase knowledge but to also mould correct attitudes and inculcate feelings of empathy.

7.1.2 Principles of History Taking in Neurology

The approach to neurological problems is to ask the following:

a. Where is the lesion e.g. peripheral nerve, root lesion, spinal cord, brain, etc?
b. What is the aetiology e.g. malignancy, infection, degeneration, etc?
c. What are the differential diagnoses?
d. Can it be treated?
e. What is the prognosis?

A good focused history is more important and useful compared to neurological examination
and investigations. In neurology, 80-85% of the diagnoses are made based on a good history
with physical examination and investigations contributing to another 8-9% each. But to be
able to take a good history, you must be familiar with the clinical presentation of common
and rare but important neurological problems.

For fits, faints, funny turns and dementia, information has to be obtained from eyewitness,
colleagues and family members. History MUST include use of prescribed drugs, recreational
drugs, over-the-counter products, alcohol and risk to HIV. Avoid stereotyping patients
especially for HIV infection as the innocent virtuous wife could be the victim of
circumstances of her philandering or intravenous drug abusing spouse.

Past and family history is important for clues to causation especially for inherited and toxic or
metabolic conditions. History of consanguinity is important for diseases with recessive mode
of inheritance. A genogram will be useful especially for diseases like Wilson’s disease.

Patients’ use of diagnostic terms like coma, fits, migraine and stroke may not really be true.
Always ask patients to specifically describe their symptoms. It is not uncommon for patients
to use interchangeably simple words like headache for dizziness and vertigo. This is
especially important in Malaysia with its multi-ethnic, multi cultural population where the
doctor from one socio-cultural, economic and educational background carries out a
conversation with patient from an entirely opposite background in a language that does not
belong to both of them (e.g. a Chinese doctor taking history from a Bangladeshi migrant
labourer in the Malay language).

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7.1.3 The Neurological examination

Most doctors perceive Neurology to be a difficult subject and unlike the cardiovascular,
respiratory and abdominal systems, neurological examinations are less likely to have been
carried out routinely. Neurological problems usually require some knowledge of the anatomy.

The neurological examination begins from the moment the patient walks into the consultation
room. You should notice his gait. Is it hemiplegic, antalgic, broad-based, high-stepping, etc?
Although most causes of walking difficulties are due to musculoskeletal problems especially
for the ageing population, an abnormal gait and posture provide a useful tool to ascertain
neurological causes. Are there tremors when walking or at rest? What is his facial
expression? How is his speech? Observe his arm swing. Is it reduced or absent on one side?

Study the patient’s face. Does it look anxious or are feelings muted? Is the face symmetrical?
Is there any ptosis? Has he got male pattern balding associated with facial weakness as in
dystrophia myotonica? Are there skin lesions like tuberose sclerosis and Sturge Weber to
account for fits?

Some important areas not to miss in examination are: palpation of temporal arteries for
headache in the elderly, hairy patch in occult spina bifida for newborns, cardiovascular
system for atrial fibrillation and cardiac murmurs in embolic stroke.

Shaking patient’s hand can also give a clue as the myotonic patient will not be able to release
your hand immediately.

Revise on how to distinguish between upper and lower motor neuron lesions and the grading
for muscle power. The pattern of distribution of motor and sensory deficits gives a clue to the
site of the lesion as well as to the causation. Glove and stocking anesthesia point to peripheral
neuropathy of which the most common cause currently is due to diabetes mellitus. Individual
nerve lesions like carpal tunnel due to median nerve entrapment are commonly encountered
in general practice. Their anatomical territories are sharply defined compared to a nerve root
lesion. A sensory level is associated with a cord lesion. Dissociated sensory loss occurs with
cervical syrinx, cord tumours or gunshot wounds. Right-sided hemiplegia indicate a left-sided
cortical lesion.

Those of us with difficulty in performing the neurological examination can have recourse to a
few avenues to refresh their memories and improve their clinical skills. There are websites on
the YouTube with videos on CNS examination.

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7.1.4 Headaches:

Headache either presenting alone or in combination with other symptoms represents one of
the most common neurological problems seen in General practice. Almost all patients have
reported at least one episode of headache in their lifetime. Women are more prone to
headache. Although most headaches are innocuous and self limiting, the Family doctor
should never miss a more sinister case requiring urgent further management and referral.
Most patients with headache have no other clinical signs and diagnosis is based from taking a
very good history. It is important for doctors in primary care to recognise dangerous
headaches for which immediate action is required to prevent death or morbidity.

Approach to Headaches

How would you approach a patient presenting with headache? Are red flags present to point
to serious life-threatening conditions that should not be missed? How do different specific
headaches present and what is their management?

Important areas to cover in the approach include

 Onset of headache-within seconds or days

 History of Injury
 Presence of fever
 Family history of headaches, brain tumours
 Progression-getting worse
 Recurrence
 Drug history

Reading Tasks (1 hour)

i. Murtagh J. Rosenblatt J. Headaches:584-600. Murtagh’s General Practice. 5th edn. Sydney:

McGraw-Hill Australia, 2011.
ii. Fuller G, Kaye C. Headaches. BMJ 2007;334:254-256.
iii. National Institute for Health and Clinical Excellence. Headaches. Diagnosis and management
of headaches in young people and adults. (Clinical Guideline 150.) 2012.
http://guidance.nice.org.uk/CG150/Guidance.

The onset of headaches can give a clue to its cause. An acute onset within minutes or hours
could be due to vascular events like intracranial haemorrhage, cerebral vein thrombosis and
embolism leading to focal weakness, numbness, stroke, cranial nerve palsies, amaurosis
fugax or fits. Other causes of severe headaches with acute onset are head injuries, migraine,
drugs like glyceryl nitrate, alcohol and other infections e.g. dengue, malaria, meningitis.

Subarachnoid hemorrhage is a rare condition with devastating sequelae. Primary care doctors
should be able to recognize some of the features of this condition. This include a history of
sudden onset within seconds to minutes of the “most severe headache ever”, a change in the
level of consciousness and sometimes focal weakness.

Headaches with sub-acute onset over days to weeks could be due to sinusitis, intracranial
space-occupying lesions, meningitis, encephalitis, hypertension emergencies, acute angle
closure glaucoma and giant cell arteritis.
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Independent Learning (1 hour)

Read the two articles and then answer the KFP questions.

i. Al-Shahi R, White PM, Davenport RJ, Lindsay KW. Subarachnoid haemorrhage. BMJ
2006;333:235-240.
ii. Bird S. Failure to diagnose: subarachnoid haemorrhage. Aust Fam Physician 2005;34:682-
683.

KFP CASE 1 (3 questions)

Sharon, a 50-year-old housewife presents with sudden onset, within seconds, of severe right-
sided headache. She nearly passed out with the pain. The headache was associated with
nausea and vomiting. She has a history of migraine since young but they usually improve
with ponstan and maxolon. However this time the headache seems to be getting worse despite
medications. She also complains of feeling feverish and has neck stiffness.

Question 1
What initial diagnoses would you consider? Write in note form only, up to TWO (2)
diagnoses.

1.
2.

Her body temperature is 37.5oC. BP 110/74 mmHg. There are no rashes. During the
examination, she is noted to become more restless, confused and irritable. She also is found
to have a left-sided weakness.

Question 2

What is your diagnosis after having examined the patient? Write in note form only, one (1)
diagnosis.

1.

Question 3

How would you manage this situation? Write in note form only, one (1) management step.

1.

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Headaches with Fever +/- Rashes

Case Scenario

A 14-year-old girl presents with a one-day history of fever and severe headache
associated with a skin rash that does not blanch. She appears very toxic and has neck
stiffness.

What life-threatening condition is she having?

What therapy should be administered immediately before transfer to hospital?
What prophylaxis should be administered to close contacts?

It is important to ask for fever when taking history in patients with acute and sub-acute onset
headaches. The presence of fever should trigger you to think of meningitis especially if
associated with classical signs of meningism like nausea, vomiting, photophobia and neck
stiffness. Look for petechial rashes. Fever, vomiting and meningeal irritation are also seen
with subarachnoid bleeding but the onset for this condition is usually very sudden, within
seconds and the fever is mild.

It is not possible clinically to differentiate viral from bacterial infections and hence all
suspected cases must be admitted. Young children and the elderly may present only with
fever, irritability or delirium. Encephalitis should be suspected if the patient develops fits, has
altered consciousness with reduced Glasgow score or has focal or diffuse neurological signs.

With the advent of vaccination, the pattern of causative organism has shifted and in UK, the
enteroviruses (Coxsackie A & B, polio virus and enterovirus 71) are now the most common
followed by Herpes simplex, Varicella zoster, HIV, EBV and CMV. Travel and sexual
history is important. Cerebral malaria with falciparum and knowlesi species presents with
fever, headache and alterations in consciousness. Dengue fever causes fever with severe
retro-orbital pain and skin rashes.

Meningococcal meningitis may present with a petechial rash. If meningococcal meningitis or

septicaemia is suspected, the current advice is to give parenteral penicillin or cefotaxime in
the clinic and then to admit patient to hospital immediately.

Reading Tasks (1 hour)

i. Murtagh J. Rosenblatt J. Infections of the CNS: 270-4. Murtagh’s General Practice. 5th edn.
Sydney: McGraw-Hill Australia, 2011.
ii. Logan SAE, MacMahon E. Viral meningitis. BMJ 2008;336:36-40.
iii. Hart CA, Thompson APJ. Meningococcal disease and its management in children. BMJ
2006;333:685-690.

Beware of headaches in the elderly as they could be due to giant cell arteritis. Look for loss
of temporal artery pulsation and raised ESR. If present, urgent treatment with steroids is
required to prevent blindness.

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Always ask for previous episodes. Recurrent headaches could be due to sinusitis, migraine,
tension or cluster headaches and paracetamol withdrawal. Migraine is episodic and is
associated with photophobia, nausea and vomiting.

Disease progression is important as headaches with increasing intensity, rapid progression

and changing character would alert you to a possible space occupying lesion. Other clinical
features pointing to an increased intracranial pressure include severe headaches which

o wake the patient up at nights

o worse in the mornings
o aggravated by straining and are relieved by vomiting.

Check for papilloedema. Urgent MRI or CT scan of brain may be needed.

Diagnostic Criteria for Headaches

The International Headache Society (IHS) has drawn up diagnostic criteria for different
headache types. (http://ihs-classification.org/en/).

Diagnostic criteria for Tension-Type Headache

A. Headache lasting from 30 minutes to seven days
B. At least two of the following criteria:
o Pressing/tightening (non-pulsatile) quality
o Mild or moderate intensity (may inhibit, but does not prohibit activity
o Bilateral location
o No aggravation by walking, stairs or similar routine physical activity
C. Both of the following:
o No nausea or vomiting (anorexia may occur)
o Photophobia and phonophobia are absent, or one but not both are present

Diagnostic criteria for Cluster Headache

A. At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting
15 to 180 minutes untreated, with one or more of the following signs occurring on the
same side as the pain
 Conjunctival injection
 Lacrimation
 Nasal congestion
 Rhinorrhoea
 Forehead and facial sweating
 Miosis
 Ptosis
 Eyelid oedema
B. Frequency of attacks from one every other day to eight per day

Diagnostic criteria for Cervicogenic Headache

A. Pain localised to the neck and occipital region. May project to forehead, orbital
region, temples, vertex or ears
B. Pain is precipitated or aggravated by special neck movements or sustained postures
C. At least one of the following:
 Resistance to or limitation of passive neck movements

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  Changes in neck muscle contour, texture, tone or response to active and passive stretching
and contraction
 Abnormal tenderness of neck muscles
D. Radiological examination reveals at least one of the following
 Movement abnormalities in flexion/extension
 Abnormal posture
 Fractures, congenital abnormalities, bone tumours, rheumatoid arthritis or other distinct
pathology (not spondylosis or osteochondrosis)

Migraine
Migraine is among the common causes of recurrent headaches which affects females two
times more than males and accounts for much suffering and medical leave.

Diagnostic criteria for Migraine without aura (MO) diagnostic criteria (IHS)
A. At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated),
which has at least two of the four following characteristics:
 Unilateral location
 Pulsating quality
 Moderate or severe intensity (inhibits or prohibits daily activities)
 Aggravated by walking stairs or similar routine physical activity
B. During headache at least one of the two following symptoms occur:
 Phonophobia and photophobia
 Nausea and/or vomiting

Diagnostic criteria for Migraine with aura (MA) diagnostic criteria

A. At least two attacks fulfilling with at least three of the following:
 One or more fully reversible aura symptoms indicating focal cerebral cortical and / or brain
stem functions
 At least one aura symptom develops gradually over more than four minutes, or two or more
symptoms occur in succession
 No aura symptom lasts more than 60 minutes; if more than one aura symptom is present,
accepted duration is proportionally increased
 Headache follows aura with free interval of at least 60 minutes (it may also simultaneously
begin with the aura
B. At least one of the following aura features establishes a diagnosis of migraine with typical
aura:
 Homonymous visual disturbance
 Unilateral paresthesias and / or numbness
 Unilateral weakness
 Aphasia or unclassifiable speech difficulty

Reading Tasks (1 hour)

i. Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine,
Tension-Type, Cluster and Medication-Overuse Headache. British Association for the Study
of Headache. Writing Committee: EA MacGregor, TJ Steiner, PTG Davies. 3rd edition (1st
revision); 2010. Available at www.bash.org.uk.
ii. Jensen S. Neck Related Causes of Headache. Aust Fam Physician 2005;34:635-639.

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Headache due to Head Injuries

Extradural haematoma is seen in 1% of head injury admitted to hospitals. Patients are

usually young as the older patients do not have this problem. There is a history of trauma
followed by headache and change in level of consciousness.

Alcohol can cause headache but beware of the alcoholic with headache due to subdural
haematoma following unrecognised head injury.

Traumatic brain injury has long term sequelae for patients and the disabilities can affect the
quality of life for patients and their families. Depending on the severity of the trauma, they
can end up with fits, chronic headache, sleep disturbance, depression, psychosis, anxiety,
dementia, aggressive or antisocial behavior. Family doctors should be aware of the impact of
these changes and offer appropriate management strategies.

Independent Learning (1 hour)

Aside from the suggested articles given, find further articles on how to distinguish extradural
from subdural and epidural haematomas. Work through these questions and reflect on your
own practice.
i. Trevena L, Cameron I. Traumatic brain injury. Long term care of patients in general
practice. Aust Fam Physician 2011; 40(12):956-61.
ii. Selvanathan SK, Goldschlager T, Udani RD, Udani SD, Jackson LM. Picture Quiz: Head
injury and decreased consciousness. SBMJ 2007;15:326-7.

7.1.5 Facial Pain

Facial pain is a common presenting problem in General practice and the most common causes
are due to dental or sinus causes. The following article on “Atypical Facial Pain” guides us
through the differential diagnoses for facial pain and presents three cases for discussion.

Trigeminal neuralgia is a very rare cause of debilitating unilateral facial pain but it is
important for the Family doctor to recognise and diagnose it because it can be treated either
medically or surgically. This paper is a clinical review based on the latest 2007 evidence
based information.

Reading Tasks (1 hour)

i. Murtagh J. Rosenblatt J. Pain in the face: 554-63. Murtagh’s General Practice. 5th edn.
Sydney: McGraw-Hill Australia, 2011.
ii. Bennetto L, Patel NK, Fuller G. Trigeminal Neuralgia and its management. BMJ
2007;334:201-205.
iii. Quail G. Atypical Facial Pain. Aust Family Physician 2005;34:641-645.

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7.1.6 Dizziness

Dizziness can mean different things to different people. It is important to know what patients
really mean when they say they are dizzy. Most cases of vertigo are of peripheral origin but it
is important to know how to differentiate peripheral from central causes of vertigo. (You
should cover peripheral causes of dizziness in the ENT Module). It is worthwhile to
remember that in the elderly, causes of vertigo are often multi-factorial in origin and needs
further evaluation.

Reading Tasks (30 minutes)

i. Murtagh J. Rosenblatt J. Dizziness / vertigo: 491-99. Murtagh’s General Practice. 5th edn.
Sydney: McGraw-Hill Australia, 2011.
ii. Kuo CH. Vertigo Part 1-Assessment in General Practice. Aust Fam Physician 2008;37:341-7.

7.1.7 Faints, Fits and Funny Turns

Syncope describes an episode of transient impairment of consciousness caused by reduced

flow of blood to the brain, usually followed by rapid and complete recovery. Although the
most common cause for syncope is vasovagal in origin (simple faint), it is important for the
doctor distinguish between this, cardiac and neurogenic causes because the treatment and
prognosis are different. In a simple faint, usually due to prolonged standing, fear or pain;
there is reflex bradycardia and peripheral vasodilatation. This accounts for the prodrome of
nausea, pallor, dizziness and cold sweat just before the faint. Once the person has fainted and
in supine position, blood returns back to the brain; recovery is rapid and complete without
incontinence or seizures. A vasovagal syncope almost never occurs in a supine position. In
contrast, an arrhythmia-induced syncope occurs without warning and can occur even in the
supine position.

Syncope can also occur during micturition, especially for the older men at night. Breath
holding or severe bouts of coughing can impede venous return of blood to the heart and lead
to a syncope. This explains why syncope can occur in a child who is holding his breath
during a temper tantrum.

Patients with tight aortic stenosis or hypertrophic obstructive cardiomyopathy can blackout
when doing strenuous exercise. Pressure on the sensitive carotid sinus can cause elderly
patients to blackout on turning their heads. Syncope can also be due to postural hypotension,
hypoglycemia, hyperventilation, panic attacks, epilepsy and TIA.

Reading Tasks (1 hour)

i. Murtagh J. Rosenblatt J. Fits, faints and funny turns: 573-80. Murtagh’s General Practice. 5th
edn. Sydney: McGraw-Hill Australia, 2011.
ii. Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic syncope. BMJ 2004;329;336-341.
iii. Mackay M. Fits, faints and funny turns in children. Aust Fam Phy. 2005;34:1003-1008.

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7.1.8 Transient Ischaemic Attacks (TIA)

Case Scenario

A 56-year-old man with diabetes, hypertension and dyslipidemia for the past 5
years is rushed to your clinic for sudden onset of right-sided weakness and
difficulty in speaking. On examination at your clinic an hour later, he is able to
speak and no neurological deficits are noted.

What condition is he having? What are the causes? How would you manage him?

Reading Tasks (1 hour)

i. National Institute for Health and Clinical Excellence. Transient loss of consciousness
(‘blackouts’) management in adults and young people. (Clinical guideline 109) 2010.
www.nice.org.uk/CG109.
ii. Leung ES, M Hamilton-Bruce A, Koblar SA. Transient ischaemic attacks. Assessment and
management. Aust Fam Physician. 2010;39(11):820-4.

7.1.9 The Unconscious Patient

Case Scenario

An old homeless man is brought to your clinic unconscious and smelling of

alcohol.

What are the likely causes of coma? How would you manage him?

7.1.10 Strokes in Adults

Case scenario

A 72-year-old man woke up with left sided weakness and numbness.

Think about what relevant history and physical examination you should carry
out. What bedside investigations can you do? How would you manage him?

Stroke is the equivalent of a heart attack but in the brain. Just as in myocardial infarct, early
diagnosis and prompt intervention can help preserve precious tissues. After cancer and heart
attacks, stroke is one of the leading causes of disability and deaths in Malaysia and the world.
With the rise in chronic diseases of hypertension, diabetes, obesity and dyslipidaemia, we can
expect a rising trend in strokes as a manifestation of cardiovascular disease complication.

For patients who survive stroke, the after-effects can be debilitating both for the patient and
his family. Not only have they lost income but human resource, time and money have to be

12
expended to care for the patient. For poorer countries where strokes occur at a younger age,
scant resources have to be expended to care for these patients.

These are many risk factors contributing to the rise in stroke. Some of them like gender, age
and genetics cannot be changed but others like smoking, obesity, over-nutrition and inactivity
are modifiable. It is the responsibility of the family doctor to prevent strokes through
counseling of patients on lifestyle changes and to detect and manage risk factors early.

Not all strokes are due to vascular events. You should exclude other conditions which can
mimic stroke. Epilepsy, hypo or hyperglycaemia, benign and malignant brain tumours,
lymphomas, brain abscess, multiple sclerosis and migraine can present with hemiplegia.

How can you assess the likelihood of your patients developing a stroke? How do you manage
a stroke that presents acutely?

Reading Tasks (1 hour)

i. Murtagh J. Rosenblatt J. The unconscious patient: 795-805. Murtagh’s General Practice. 5th
edn. Sydney: McGraw-Hill Australia, 2011.
ii. Clinical Practice Guidelines. Management of ischaemic stroke. 2nd Edn. 2012. Malaysian
Society of Neurosciences, Academy of Medicine of Malaysia, Ministry of Health Malaysia.
MH/P/PAK235.12(GU).
iii. Dhamija RK. Time is brain. Acute stroke Management. Australian Family Physician.
2007;36:892-895.

After a stroke, what are the responsibilities of the Family doctor for long term and continuing
care? What are the interventions and secondary preventive measures that should be
instituted? Who else should be co-opted to help in rehabilitation?

Reading Tasks (1 hour)

i. Charles J, Miller G, Fahridin S. Management of stroke in general practice. Australian Family

Physician 2007;36:890-891.
ii. Lindley RI. Community care after stroke. Australian Family Physician. 2007;36:914-917.
iii. Young J, Forster A. Rehabilitation after stroke. BMJ 2007;334:86-90. doi:
10.1136/bmj.39059.456794.68. [Accessed on 3 November 2008].

7.1.11 Strokes in children

Although we often see strokes in adults, children can suffer from strokes too although the
occurrence is less common. But the effects and burden on the child and his family are more
devastating due the young age of the child and his future.

Independent Learning (1 hour)

This paper discusses the risk factors, diagnosis, management of stroke in children.

i. Mackay MT. Stroke in children. Australian Family Physician. 2007;36:896-902.

Work on the questions from CHECK and clinical challenge.

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 i. CHECK on Stroke. Unit 454/455 January/February 2010
ii. O’Connor Kath. Clinical challenge. Australian Family Physician. 2007;36:943. (Answers in
Dec 2007 issue).

7.1.12 Fits, Funny Turns and Epilepsy

When you take history for a patient presenting with abnormal movements, ask yourself:

What is the likely problem? Is it epilepsy, absence, myoclonus, tremor, chorea, dystonia, tics,
etc? What is the underlying aetiology? Is it space occupying lesion, drugs (recreational or
iatrogenic), anxiety with hyperventilation or psychogenic?

Seizures in General Practice is not uncommon. When dealing with seizures, there are many
questions to consider. What do you do if a patient presents for the first time with a seizure?
How do you assess the patient and make an accurate diagnosis of the type of seizures? How
do you classify the different types of eplileptic seizures? What are the newer drugs? What
drug works for the different types of epilepsy? How do you start treatment? How do you
monitor treatment? When can you stop treatment? What advice do you give patients on
driving, employment, sports, pregnancy, contraception? How do you manage your patient in
pregnancy? What is status epilepticus and how to manage it? When should you refer a patient
with seizures for specialist’s opinion and when must you admit patients to hospital
immediately?

Important Points in History Taking

 Is it acute or chronic
 Exact nature of movement – described by patient / witness (“Exactly, what do you mean by
funny movement?”)
 Localised
 Generalised
 Loss of consciousness

Symptoms before event (pre-ictal)

 Precipitating events – illness, trauma, toxins , current medications , drugs, stress, head
movement, pain, sleep deprivation, etc
 Health at onset - febrile, ill, exposed to illness, travel, etc.,
 Aura: Subjective sensations like smell, feelings
 Behaviour - mood or behavioural changes before the seizure

Symptoms during event / seizure (ictal)

 Motor: head or eye turning, eye deviation, posturing, jerking (rhythmic), stiffening,
automatisms (purposeless repetitive movements such as picking at clothing, lip smacking),
generalized or focal movements
 Vocal: cry or gasp, slurring of words, garbled speech
 Respiration: change in breathing pattern, cessation of breathing, cyanosis
 Autonomic: pupillary dilatation, drooling, change in respiratory or heart rate, incontinence,
pallor, vomiting
 Loss of consciousness or inability to understand or speak
 How long did the convulsion last?

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  What did witness do?

Symptoms following event / seizure (postictal)

 Amnesia for events
 Confusion
 Lethargy
 Sleepiness
 Headaches and muscle aches
 Transient focal weakness (Todd’s paresis)
 Nausea or vomiting

Clinical presentation, causes, management and impact of epilepsy are different in the elderly
compared to the young. The review paper by Brodie discusses some of the challenges and
recent development for management of this disease in old people.

Reading Tasks (1 hour)

i. National Institute for Health and Clinical Excellence. The epilepsies: the diagnosis and
management of the epilepsies in adults and children in primary and secondary care (update).
(Clinical guideline 137.) 2012. http://guidance.nice.org.uk/CG137.
ii. Brodie MJ, Kwan P. Epilepsy in older people. BMJ 2005;331:1317-1322.
iii. Brodie MJ, Kwan P. Newer drugs for focal epilepsy in adults. BMJ 2012;344:e345 doi:
10.1136/bmj.e345.

Tips for General Practitioners [adapted from Brodie MJ, Kwan P. Newer drugs for focal
epilepsy in adults. BMJ 2012;344:e345 doi: 10.1136/bmj.e345]

• Refer patients with suspected epilepsy to an epilepsy specialist or neurologist for diagnosis,
investigation, and initial treatment
• Patients planning a pregnancy should be referred to an epilepsy specialist for advice,
optimisation of the antiepileptic drug regimen. You should initiate folic acid
• Patients with epilepsy who become pregnant should in addition be referred to an
obstetrician for shared care
• When introducing adjunctive treatment in a patient with drug resistant epilepsy it may be
necessary to reduce the dose of one of the other drugs, particularly if this is being taken at a
high dose, to facilitate optimal tolerability
• If a clinical problem occurs after an antiepileptic drug monotherapy or multidrug regimen
has been stable for some years, the problem is unlikely to be caused by the antiepileptic drugs
• Routine therapeutic drug monitoring of antiepileptic drugs is not necessary. Use monitoring
only to ask a clinical question, such as whether the patient is complying with the treatment
• If a patient is considering stopping treatment, advise him or her to discuss the risks with an
epilepsy specialist before finalising the decision

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Independent Learning (1 hour)

Read the following:

i. Consensus Guidelines on the Management of Epilepsy. 2005. Epilepsy Council, Malaysian

Society of Neurosciences.
ii. Morrison M, Thomas R, Smith P. Juvenile myoclonic epilepsy. A patient’s journey. BMJ
2012;344:e360 doi: 10.1136/bmj.e360.
iii. Hocking B. Landgren F. New medical standards for drivers. Driving and epilepsy. Should a
patient with epilepsy drive? Aust Fam Phy. 2003;32:732-736.

Reflect on the experience, trials and tribulation of the patient diagnosed with epilepsy and her
subsequent reconciliation with her condition. How would you feel if you are diagnosed with
epilepsy?

Reflect on this article on driving and epilepsy. Do we have driving standards in Malaysia?
Have we always been ethical and professional when certifying fitness for driving, especially
for public vehicles? Are we putting other passengers, pedestrians and the driver at risk?

7.1.13 Movement Disorders

The commonest movement disorder presenting in primary care is that of tremors. A tremor is
a rhythmic involuntary muscular contraction usually of the hands but can occur in the jaws
and other parts of the body. It is important to observe the tremors. If present at rest, it can be
due to parkinsonism. Intention tremor signifies cerebellar disease. Benign tremors improve
with alcohol consumption, although this should not be taken as a excuse for patients to drink.

7.1.14 Parkinson’s disease

Case scenario

A 68-year-old man is brought in by his wife for resting tremors and walking
problem.
How can you be sure it is Parkinson’s disease? When should treatment be
commenced? Are there side effects? As a Family doctor what other care needs to be
organised for this patient? Is there new treatment or surgery in the horizon?

Parkinson’s disease affects 1% of patients who are older than 65 years. The Malaysian
Consensus guideline on Parkinson’s disease will provide information on how to diagnose and
care for your patients and the newer treatment modalities available.

Reading Tasks (1 hour)

i. Clarke CE. Parkinson’s Disease. BMJ 2007;335:441-445.

ii. Sng KH, Easaw S. Consensus on the Management of Parkinson’s disease. Malaysia Parkinson
Disease Society. 2006.
iii. Scottish Intercollegiate Guidelines Network. Diagnosis and pharmacological management of
Parkinson’s disease. Edinburgh: SIGN, 2010. (SIGN publication No. 113)
www.sign.ac.uk/guidelines/fulltext/113/index.html. [Accessed on 12 Oct 2012].

16
7.1.15 Delirium and Dementia

Delirium is condition that usually occurs acutely but can have subacute presentation. There is
fluctuating impairment of consciousness associated with changes in behaviour. Patients can
be agitated and sometimes violent. They may have hallucinations and delusions. Delirium is
more likely to occur in the elderly and is more common at night when it starts to get dark. It
is important to rule out medications and infections, especially of the urinary tract and
respiratory system, as causes of delirium.

Dementia is a condition where there is progressive usually global decline in cognitive

function without any change in the level of consciousness. The two most common causes of
dementia are Alzheimer’s disease and cerebral multi-infarcts. Other causes are Lewy bodies
head trauma (boxers, accidents), vitamin B12 deficiency, chronic alcoholism, syphilis,
hypothyroidism, etc.

Reading Tasks (1 hour)

The 2nd article guides you to diagnose, manage and prevent delirium in the elderly.

i. Workman B, Dickson F, Green S. Early dementia. Optimal management in general practice.

Aust Fam Physician 2010;39(10): 722-6.
ii. Young J, Inouye SK. Delirium in Older People. BMJ 2007;334;842-846.
doi:10.1136/bmj.39169.706574.AD.
iii. Chan DKY, Ruetens S, Liu DKW, Chan RO. Frontotemporal dementia. Features, diagnosis
and management. Aust Fam Physician 2011; 40(12):968-72.

Independent Learning (1 hour)

Clinical Practice Guidelines. Management of dementia. 2nd Edn. 2009. Ministry of Health
Malaysia, Malaysian Psychiatric Association, Academy of Medicine of Malaysia, Malaysian
Society of Neurosciences. MOH/P/PAK/196.09(GU). Available at www.psychiatry-
malaysia.org, www.neuro.org.my, www.moh,gov.my, www.acadmed.org.my

National Institute for Health and Clinical Excellence. Delirium: diagnosis, prevention and
management. (Clinical guidline 103. ) 2010. www.nice.org.uk/CG103.

17
7.1.16 Spinal Cord Lesions

Case scenario

A 62-year-old woman with history of cervical cancer presents with lower thoracic back
pain associated with paresthesia and Grade 4 lower limbs weakness for three days.

What diagnosis should you not miss?

Why must you ask and ask for bladder and bowel function?
What is the danger if you procrastinate?

Reading Task (1 hour)

i. Murtagh J. Rosenblatt J. Walking difficulties and leg swelling:744-50. Murtagh’s General

Practice. 5th edn. Sydney: McGraw-Hill Australia, 2011.
ii. Quraishi NA, Esler C. Easily Missed? Metastatic spinal cord compression. BMJ
2011;342:d2402 doi: 10.1136/bmj.d2402.

7.1.17 Neuropathies and Myopathies

Carpal Tunnel syndrome is the commonest peripheral nerve problem seen in General
Practice and may have been covered in the Module on Musculoskeletal Problems.

Bell’s Palsy

This is a common condition seen in primary care. GPs should learn how to distinguish upper
from lower facial nerve palsy and to determine the underlying cause so that the appropriate
treatment is prescribed. Recent findings indicate that early treatment with prednisolone
improves Bell’s palsy.

Case Scenario

A 24-year-old model woke up with facial asymmetry. She is unable to close

her left eye. She is generally healthy and has no significant previous
problems. Naturally she is very worried about her appearance and anxiously
asks if there is any treatment.

18
Reading Task (30 minutes)

Bland. JDP. Carpal Tunnel syndrome. BMJ 2007;335:343-346.

Madhok V, Falk G, Fahey T, Sullivan FM. Prescribe prednisolone alone for Bell’s palsy
diagnosed within 72 hours of symptom onset. BMJ 2009;338:b255 doi:10.1136/bmj.b255.
[accessed on 12 Oct 2012].

7.1.18 Rare but Important Conditions

Guillain-Barré syndrome is actually an acute inflammatory demyelinating peripheral

neuropathy which although rarely encountered in primary care is important because if not
diagnosed early and admitted, can lead to death. This is an emergency that should be
recognized immediately should you see a case of rapidly progressive limb weakness
associated with the RED FLAG of absent reflexes.

Another rare disorder leading to progressive paralysis is motor neurone disease. Although
seldom encountered, this disease has devastating consequences on the patient and his family.
Hence it is important that the Family doctor should be able to rule out the disease, if absent,
to allay anxiety. For affected patients, the doctor should be able to diagnose, counsel and
advise on management for the patient and his family. This latest clinical review by
McDermott et al addresses the issues and current management for this condition.

Myasthenia Gravis is a rare condition. Patients usually present first to their GPs. Hence GPs
should recognize and offer advice on latest treatment regimes.

Multiple sclerosis is yet another rare condition seen more in the West than in Malaysia. It is
important for you to diagnose this condition, refer to neurologist and to provide long term
support for patients and their families.

Reading Tasks (1.5 hours)

i. Murtagh J. Rosenblatt J. Murtagh’s General Practice. Neurological Dilemmas.

ii. 5th edn. Sydney: McGraw-Hill Australia, 2011: 291-306.
iii. Winer JB. Guillain-Barré syndrome. BMJ 2008;337:227-231.
iv. McDermott CJ, Shaw PJ. Diagnosis and management of motor neurone disease. BMJ
2008;336:658-662.
v. Zoing M, Kiernan M. Motor neurone disease. Caring for the patient in general practice. Aust
Fam Physician 2011; 40(12):962-66.
vi. Gilhus NE, Owe JF, Hoff JM, Romi F, Skeie GO and Aarli JA. Myasthenia Gravis: A Review
of Available Treatment Approaches.Tsang BKT, Macdonell R. Multiple sclerosis diagnosis,
management and prognosis. Aust Fam Physician 2011;40 (12):948-55.

19
Independent learning (1 hour)

Read this review paper on Restless Legs Syndrome. Reflect on the cases you have seen. Have
you managed your cases appropriately?
i. Leschziner G, Gringras P. Restless legs syndrome. BMJ 2012;344:e3056 doi:
10.1136/bmj.e3056. [Accessed on 12 Oct 2012].

Work through this Clinical Challenge:

ii. Valentine N. Clinical Challenges. Aust Fam Physician 2011; 40(12):1019-20.

7.2 Endocrine Problems

7.2.1 Overview of Thyroid and other Problems

Thyroid problems represent the second most common endocrine disorders seen in General
Practice. The most common is Type 2 diabetes mellitus which is covered in Chronic Disease
Module. By now, you should be able to take an adequate focused history and competently
perform an examination of the neck and related systems to assess the thyroid function and the
likely underlying causes.

Thyroid problems tend to occur more in women. Hence you should also know how to manage
thyroid problems in pregnancy and when to refer for joint care with the endocrinologist and
the obstetrician.

Reading Task (1 hour)

Read
i. Murtagh J. Rosenblatt J. Thyroid and other Endocrine problems:211-21. Murtagh’s General
Practice. 5th edn. Sydney: McGraw-Hill Australia, 2011

7.2.2 Thyrotoxicosis

Case Scenario

Nora, a 22-year-old final year University student presents just before her final
examination with multiple problems of insomnia, feeling “jittery all the time and
daytime increased frequency of micturition. She also noticed weight loss despite
eating more. Her menses are irregular and scanty.

On examination, she has fine finger tremors and her palms are warm but not sweaty.
Her pulse rate is 100 per minute and blood pressure reading is 120/60 mm Hg. Height
is 160 cm and her weight is 40 kg. It was 48 kilograms a year ago.

What is your provisional diagnosis?

What else should be examined?
What investigations should be ordered?

20
Reading Tasks (2 hours)

These articles discuss the clinical features, causes, investigations, diagnosis and medical and
surgical management of thyrotoxicosis.

i. Brent GA. Graves’ Disease. N Engl J Med 2008;358:2594-605.

ii. Campbell K, Doogue M. Evaluating and managing patients with thyrotoxicosis. Aust Fam
Physician 2012; 41(8):564-72.
iii. Marx H, Amin P, Lazarus JH. Hyperthyroidism and pregnancy. BMJ 2008;336;663-667
doi:10.1136/bmj.39462.709005.AE
iv. Reid JR, Wheeler SF. Hyperthyroidism: Diagnosis and Treatment. Am Fam
Physician;2005;72(4):623-30.
v. Cuthbertson DJ, Davidson J. What to tell patients about radioiodine therapy. BMJ
2006;333:271-272.

7.2.3 Hypothyroidism

Case Scenario

Laura, a 28-year-old woman presents with tiredness, difficulty

concentrating and a decline in memory over the last few months. She
complains of putting on too much weight, constipation and menorrhagia.
Her mother and sister have thyroid problems.

BMI is 29.8 kg/m2, BP 138/88 mmHg Pulse 58 bpm. She has puffy
eyelids. Her thyroid is not palpable. The deep tendon reflexes shows
delayed relaxation.

What is the most likely diagnosis?

What tests should be ordered and how would you interpret their results?
How would you manage her?

Laboratory Results Interpretation

Review the thyroid function tests ordered for this 40-year-old man
suspected to have hypothyroidism.

TSH 0.1 mU/L (normal 0.27 to 4.2 mU/L)

Free T4 8 pmol/L (normal 10 to 24 pmol/L)
Free T3 1.8 pmol/L (normal 3 to 6.5 pmol/L)

Interpret the results

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Reading Tasks (1 hour)

i. So M, MacIsaac RJ, Grossmann M. Hypothyroidism investigation and management. Aust

Fam Physician 2012; 41(8):556-62.
ii. Vaidya B, Pearce SHS. Management of hypothyroidism in adults. BMJ 2008;337:284-289.
iii. Clemens K, Payne W, Van Uum Stan HM. Central hypothyroidism. Can Fam Physician
2011;57(6):677-80.

7.2.4 Thyroid Nodules

Case Scenario

A 35-year-old man presents with enlargement of left anterior neck. He has

noted increased appetite over past month with no weight gain, and more
frequent bowel movements over the same period.

BMI is 24.8 kg/m2, BP 130/70 mmHg Pulse 90 bpm, irregular. The

thyroid gland is enlarged with a 3 x 2.5cm firm nodule in the left lobe.
There is no cervical lymphadenopathy.

What is the most likely diagnosis?

What tests should be ordered and how would you interpret their results?
How would you manage him?

Reading Tasks (1 hour)

i. Mehanna HM, Jain A, Morton RP, Watkinson J, Shaha A. Investigating the thyroid nodule.
BMJ 2009;338:b733 doi:10.1136/bmj.b733.
ii. Hughes K, Eastman C. Goitre. Causes, investigation and management. Aust Fam Physician
2012; 41(8):556-62.
iii. Lee JC, Harris AH, Khafagi FA. Thyroid scans. Aust Fam Physician 2012; 41(8):584-86.
iv. Brennan M, French J. Thyroid lumps and bumps. Aust Fam Physician 2007; 36(7):531-536.

Independent Learning (1 hour)

By now, you should be able to deal with most thyroid problems arising. Answer the questions
to the above scenarios and attempt these quizzes.

i. Philips PJ. Thyroid therapy. Tips and Tricks. Aust Fam Physician. 2012; 41(8):589-91.
ii. Parsons J (ed.) CHECK on Thyroid. Unit 462. September 2010 (this is an independent
learning programme under RACGP).

22
7.2.5 Cushing’s Syndrome

Not all hot flushes, irregular periods and weight gain are due to the menopause. You should
think of other endocrine causes especially Cushing syndrome. The paper by Philips describes
the skin manifestation of the condition as well as the tests required to confirm the diagnosis.

Reading Task (15 minutes)

i. Philips PJ. Skin and Cushing Syndrome. Australian Family Physician. 2007; 36:545-547.

Discuss
What is the difference between Cushing disease and syndrome and how would you
differentiate their causes?

7.2.6 Addison’s Disease

Addison’s disease is a rare but life-threatening condition which the Family doctor MUST
recognise because it can lead to death if diagnosed late. In her paper on professional practice
and risk management, Bird (2007) illustrates an actual case of an adolescent who died as a
result of missed diagnosis. She also describes the clinical features, laboratory clues and the
definitive test for this disease.

Reading Task (30 minutes)

i. Vaidya B, Chakera AJ, Dick C. Easily Missed? Addison’s disease. BMJ 2009;339:
ii. Bird S. Failure to diagnose: Addison disease. Aust Fam Physician. 2007; 36:859-861.

7.2.7 Acromegaly

This rare condition usually due to a benign pituitary tumour occurs equally in both men and
women. It can present as headache with bitemporal hemianopia, hypertension, diabetes or
with hypopituitarism. The onset is insidious and can be missed but if you suspect the disease,
you should compare patient’s features with that of his old photographs.

7.2.8 The Parathyroid hormones

Although parathyroid problems are seldom encountered in primary care, occasionally we

come across hypercalcaemia as an incidental finding in our cases. According to the
endocrinologists, 90% of them are due to primary hyperparathyroidism.

More often we see hypocalcaemia presenting with Trousseau’s sign due to anxiety-induced
hyperventilation.

Reading Tasks (1 hour)

i. Marcocci C, Cetani F. Primary Hyperparathyroidism. N Engl J Med 2011;365:2389-97.

ii. Blackburn M, Daimond T. Primary hyperparathyroidism and familial hyperparathyroid
syndromes. Aust Fam Physician 2007;36(12):1029-1033.

23
 iii. Cooper MS, Gittoes NJL. Diagnosis and Management of hypocalcaemia. BMJ
2008;336:1298-1302.
iv. Pallan S, Rahman MO, Khan AA. Diagnosis and management of primary
hyperparathyroidism. BMJ 2012;344:e1013 doi: 10.1136/bmj.e1013.
v. Fong J, Khan A. Hypocalcemia: Updates in diagnosis and management for primary care. Can
Fam Physician. 2012;58(2):158-62.
7.2.9 Phaeochromocytoma

Phaeochromocytoma is a very rare but important endocrine disorder as it a known secondary

cause of hypertension.

Reading Task (15 minutes)

i. Jones AG, PH Evans, Vaidya B. Easily missed? Phaeochromocytoma. BMJ 2012;344:e1042.

doi: 10.1136/bmj.e1042. [Accessed on 12 Oct 2012].

7.2.10 Galactorrhoea

Aside from lactating mothers, male and female newborns can very occasionally present with
galactorrhoea due to influence from maternal hormones. The presence of galactorrhoea at
other times is usually due to medication. Sometimes it can be a cause of menstrual disorders
and infertility due to associated hyperprolactinoma from disease at the level of the pituitary.

Reading Task (15 minutes)

i. Leung AKC, Pacaud D. Diagnosis and Management of Galactorrhea. Am Fam Phy

2004;70(3):543-550

7.2.11 Hypogonadism in men.

Reading Task (15 minutes)

i. Newman JD. Assessing hypogonadism in men. Aust Fam Physician 2008;37:670-671.

7.2.12 Hirsutism

Case Scenario

Maria, a beautiful 21-year-old aspiring model is worried about her

facial hair. She also has to shave her legs very often.

How would you approach the problem?

24
Reading Task (15 minutes)

i. Markovski M, Hall J, Jin M, Laubscher L, Regier L. Approach to the management of

idiopathic hirsutism. Can Fam Physician. 2012;58(2):173-7.

7.2.13 Carcinoid

Case Scenario
A 42-year-old woman presents with intermittent facial flushing for
the past one year. She is worried that she will go into early
menopause although she is still menstruating regularly. She gives a
one-year history of diarrhoea and episodic abdominal pain with no
clear precipitating factors. Investigations for chronic diarrhoea
including colonoscopy are all negative.
How would you approach the problem?

Not all facial flushing is due to the menopause. This condition is very rare and often missed.
Read this article.

Reading Task (15 minutes)

i. Srirajaskanthan R, Shanmugabavan D, Ramage JK. Easily missed? Carcinoid syndrome.

BMJ 2010;341:c3941. doi: 10.1136/bmj.c3941. [Accessed on 12 Oct 2012].

7.2.14 Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

Case Scenario

A 70-year-old man in a nursing home is referred to you for delirium. He

was a heavy smoker and has developed bronchial carcinoma.

Results of blood tests show a persistent euvoloemic hyponatremia with

sodium 122 mmol/L (normal range 136-146 mmol/L). He is not on
diuretics. Syndrome of inappropriate antidiuretic hormone secretion
(SIADH) is suspected.

What is SIADH?

Reading Task (15 minutes)

i. Wakil A, Ng JM, Atkin SL. Rational Testing. Investigating hyponatraemia. BMJ

2011;342:d1118. doi: 10.1136/bmj.d1118.

25