NEUROLOGY REFERRAL RECOMMENDATIONS

     Diagnosis / Symptomatology                            Evaluation                            Management Options                              Referral Guidelines
                                            Key factors in the neurological history     As per individual diagnosis.               As indicated below
The following diagnoses or symptoms         include:
are considered under Neurology:
                                            -       Neonatal History
-        Carpal tunnel and other            -       Drug History – including oral
         entrapment syndromes                       contraceptives
-        Headaches & Migraine               -       Head injury
-        Parkinsonism                       -       Previous intracranial infections
-        Progressive loss of Neurological   -       Alcohol
         function                           -       Family history
-        Movement Disorders                 -       Occupation
-        Neurological symptoms in           -       Pregnancy issues
         pregnancy                          -       Psychiatric and psychosocial
-        Seizures                                   history
-        Strokes & TIA
-        Tremor

The following conditions that are commonly referred to Neurology should be referred elsewhere in most cases:

Diagnosis or Symptoms                                                             Rationale:
Sleep Disorders / Narcolepsy                                                      Many of these conditions require a formal sleep study to make the diagnosis
Back Pain which has been fully investigated, with no surgical solution, and       A pain clinic would be more appropriate to address the problem with a multi-disciplinary approach
the patient is already taking medical therapy                                     and consider invasive therapies.
Elderly patients with complex medical problems                                    Referral to an Extended care physician is often more appropriate to address the multiple issues
                                                                                  including how the patient is managing in home /hostel.

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     Diagnosis / Symptomatology                      Evaluation                             Management Options                            Referral Guidelines
Carpal Tunnel and other Entrapment Syndromes
Carpal Tunnel Syndrome                Typically intermittent tingling in hand or   Arrange for steroid injection and hand   Consider referral for neurophysiology for
                                      hands, predominantly nocturnal               splints                                  confirmation of diagnosis and to assess severity

                                                                                                                            Seek an orthopaedic opinion first
                                      If symptom predominantly of pain with
                                      little or no tingling

                                                                                                                            Consider referral to neurophysiology for nerve
                                      Consider: Diabetes, Hypothyroidism if                                                 conduction studies
                                      no other reasons for carpal tunnel
                                      syndrome developing
Other suspected isolated nerve
entrapment syndromes
Suspected or definite papilloedema    Nil further by GP                            Depends on diagnosis                     All patients should be referred to
without other neurological                                                                                                  ophthalmologists in the first instance.
symptoms/signs                                                                                                              Telephone consult would be appropriate with
                                                                                                                            ophthalmology or neurology departments.
Back and Neck Pain                                                                                                          Referral should be directed primarily to
                                                                                                                            rheumatologist or orthopaedic surgeons

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     Diagnosis / Symptomatology                     Evaluation                        Management Options                              Referral Guidelines
Acute: Sudden onset/thunderclap or   Look for neck stiffness, signs of       Subarachnoid haemorrhage suspected.        Immediate referral to acute service – Category1.
severe occurring after exercise      meningism.
Severe disabling headache            May require urgent imaging              Pain relief/avoid sedatives or CNS         Seek telephone advice or urgent neurological
                                                                             depressing drugs.                          opinion.
Chronic                              Important to identify the two common
                                     causes of headache, ie:
                                     -      Tension headache
                                     -      Migraine
                                                                                                                        Neither of which should require a neurologist
                                     Tension headache: dull non disabling,   Consider ergonomic, postural, stress       referral unless there are problems with
                                     pressure or tightness type sensation    related problems                           management or concerns about the presence of
                                     without nausea, photophobia                                                        intracranial lesions – Category 4.
                                                                             Try low dose amitriptyline (explain the
                                                                             danger of chronicity)
                                                                                                                        Refer to neurologist with any specific concerns –
                                                                             Avoid locking the patient into treatment   Category 4.
                                                                             of assumed neck problems and multiple
                                                                                                                        If symptoms do not resolve then refer to a
                                                                             If focal, then consider sinus disease,     neurologist – Category 4.
                                                                             Temperomandibular joint dysfunction,
                                                                             dental disease, local eye problems, e.g.
                                     Migraine:                               Dietary advice, hormone manipulation if    Not for a typical presentation
                                     Paroxysmal or intermittent headache     catamenial.
                                     with association of nausea,
                                     photophobia, phonophobia, and some      Consider prophylaxis in selected case
                                     disability. Duration of 4 – 72 hours
                                                                             Acute treatment with
                                                                             analgesia/sumpatriptan* as appropriate

Last updated February 2006                                                                                                                               Page 3 of 6

     Diagnosis / Symptomatology                       Evaluation                        Management Options                          Referral Guidelines
Movement disorders                   Assessment of chorea, dystonia or other                                          Refer to Neurologist – Category 3
                                     involuntary movements.

     Diagnosis / Symptomatology                       Evaluation                        Management Options                          Referral Guidelines
Neurological symptoms in pregnancy   Routine history and examination           Depends on Diagnosis                   Patients should be dealt with promptly initially
                                                                                                                      with telephone consultation and then suitable
                                                                                                                      arrangements made – Category 1 – 2
Vertigo, unaccompanied by other      ENT/neurological examination                                                     Neurology/ ENT referral – Category 1
neurological symptoms

Visual disturbance                   Hemianopia                                                                       Neurology/ophthalmology referral – Category 1
                                     Visual failure

                                     Amaurosis fugax                           Treat as TIA

     Diagnosis / Symptomatology                       Evaluation                        Management Options                          Referral Guidelines
Parkinsonism                         Drug history eg Phenothiazines                                                   Referral for consideration of causes and
                                     Cognitive and bladder function                                                   confirmation of the disease prior to commencing
                                     assessment                                                                       medication – Category 4

                                     End stage Parkinson’s Disease and         Consider disability support services
                                     drug treatment refractory                 when appropriate

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     Diagnosis / Symptomatology                  Evaluation                           Management Options                                Referral Guidelines
Progressive loss of Neurological   Cognitive disturbance                                                                  Consider physician for elderly if in appropriate
function                           Disturbance of swallowing and speech                                                   age group – Category 3.
                                   Spinal cord lesions
                                   Balance problems
                                   Muscle wasting and weakness                                                            All these condition require referral to a
                                   Loss of sensation                                                                      neurologist for assessment and investigations –
                                   Neuropathy                                                                             Category 3.

                                   Consider diabetes, alcohol, B12
                                   deficiency paraproteinaemia, syphilis,
                                   autoimmune disease in appropriate

     Diagnosis / Symptomatology                  Evaluation                           Management Options                                Referral Guidelines
Seizure                            Important to define the difference        If syncope, elimination of potential
                                   between syncope and seizure based on      triggers (most patients do not need
                                   the history                               referral)

                                      Single seizure in child or            Observation                                  All patients should be referred for specialist
                                       adolescents: establish presence of    EEG                                          assessment after the first seizure – Category 3.
                                       family history, risk factors for      Sodium Valproate may be commenced
                                       epilepsy, triggers (eg flashing TV    after the second seizure prior to referral
                                       screens, photosensitivity), eye       for specialist assessment.
                                       witness account of seizure.
                                                                                                                          These patients need urgent referral for
                                      Focal features/finding or suspicion                                                comprehensive investigation – Category 2.
                                        of underlying neurological disease
                                                                             Check compliance,
                                      Ongoing seizures : Patients with      Optimise Dose                                Once a patient has been stabilised, ongoing
                                       chronic, poor or deteriorating        Blood levels if queries of compliance or     care should be provided by the GP with access
                                       seizure control                       toxicity (routine level monitoring is not    to specialist review on an “as required” basis.

                                                                             NB: Optimisation means increasing the
                                                                             dose to achieve seizure control or until
                                                                             problematic side effects occur
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     Diagnosis / Symptomatology                            Evaluation                          Management Options                              Referral Guidelines
Note: Stroke or TIAs could be the result
of either a haemorrhage or a thrombo-
embolic stroke.
Acute loss of function with persisting     Emergency assessment of admission          Suspected Subarachnoid Haemorrhage         High index of suspicion for SAH needed. Any
deficit                                    important to establish whether the         requires urgent admission                  suggestion of thunder-clap headache or
                                           patient has had a haemorrhage or not.                                                 headache brought on acutely by exercise needs
                                                                                                                                 this diagnosis excluded by CT scan and or LP –
                                                                                                                                 Category 1.
All patients with stroke require risk      Check:                                     A.      If lasting deficit or age  45     Admissions as per condition to acute facility or
factor analysis.                           1.      Hypertension                               years (younger subjects require    to a rehabilitation unit – Category 1.
                                           2.      Smoking history                            extensive special and urgent
                                           3.      Diabetes                                   investigations)
                                           4.      Serum LIPIDS
                                           5.      ESR, FBC                                                                      Treat as TIA (see below)
                                           6.      Cardiac abnormality                B.      If complete recovery
                                           7.      Clotting abnormality (in younger
                                                   subjects only)
TIA single                                 Risk factor analysis                       Treat underlying condition and Aspirin     Refer to an ultrasound facility private or public
                                                                                      so long as cardiac cause excluded.         for an urgent scan of the carotid and or vertebral

                                           If atrial fibrillation or cardiac cause    Refer to appropriate speciality            For consideration of urgent anti-coagulation.
                                                                                                                                 Refer to neurology service for admission –
                                           Multiple TIAs or crescendo TIAs            Require urgent intervention                Category 1.

     Diagnosis / Symptomatology                            Evaluation                          Management Options                              Referral Guidelines
Tremor                                     Two main types:
                                           1. Postural = tremor which occurs
                                               during use of the limb usually the
                                               hands and is absent at rest.           No Treatment or trial of Propranalol (or
                                               Common cause benign essential          other beta blockers), primidone.
                                               tremor, drug induced (eg, alcohol
                                               withdrawal, lithium) thyrotoxicosis,
                                               metabolic derangement.

                                           2.   Rest Tremor = with or without other
                                                features of Parkinson’s disease                                                  Refer to Neurologist – Category 4

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