Conditions of the Nervous System

This document has been endorsed by the American Academy of Family Physicians and the American Academy of Neurology and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

The goal of these guidelines is to sensitize the family practice resident to neurologic disease and familiarize residents with its particular place in the overall practice of family medicine. Neurologic problems are estimated to comprise 10 to 15 percent of a family physicians workload. The specialty of family practice is vitally interested in all aspects of neurologic disease. History-taking in neurology and performance of the neurologic examination are essential skills. Emphasis on good diagnostic and therapeutic skills and appropriate consideration of biopsychosocial factors must be included in the curriculum.

Attitudes

The resident should develop attitudes that encompass:

A humanistic and compassionate approach to care of the patient with neurologic disease, especially in the case of patients with chronic disorders.
Recognition of the importance of family, home, and social support in the overall life of patients with neurologic disease.
Recognition of the physician's own level of competence in handling neurologic problems and the need for further consultation as appropriate.
Utilization of self-directed learning toward further knowledge and competence in neurology.
Understanding the role of the neurology consultant and the concept of shared care for certain neurologic conditions.
Support of the patient through the process of consultation, neurologic evaluation, treatment, rehabilitation and long-term care

Knowledge

The resident should develop knowledge of:

Normal anatomy, physiology and anatomic principles that allow localization of neurologic disease
Normal growth, development and senescence of the nervous system
Pathologic neurologic disorders to include:
1. Disorders of motor function
  1. Upper and lower motor neuron disorders
  2. Incoordination
  3. Movement disorders
    1. Hypokinetic
      1. Parkinson's disease
      2. Parkinson plus syndromes
    2. Hyperkinetic
      1. Athetosis
      2. Chorea
      3. Dystonia
      4. Tics
      5. Tremor
2. Disorders of sensation
  1. Central
  2. Peripheral
3. Disorders of vision
  1. Visual field defects
  2. Monocular and binocular blindness
  3. Diplopia and gaze palsies
  4. Nystagmus
  5. Pupillary abnormalities
4. Cerebrovascular diseases
  1. Ischemic stroke
    1. Thrombolytics
      1. Indications and use
      2. Risks and benefits
  2. Hemorrhagic stroke
  3. Vasculitis
  4. Transient Ischemic attacks
  5. Symptomatic/asymptomatic carotid stenosis
  6. Aneurysmal disease
5. Head and spinal cord trauma
  1. Evaluation
  2. Management
  3. Consequences
6. Multiple sclerosis
  1. Diagnostic criteria
  2. Laboratory findings
  3. Management
7. Dizziness and disorders of hearing
  1. Central vs. peripheral hearing loss
    1. Acute
    2. Chronic
  2. Central vs. peripheral vertigo
    1. Acute
    2. Chronic
    3. Evocative testing (e.g., Hallpike maneuver)
  3. Tinnitus
8. Disorders of higher cognitive function and communication
  1. Dementia
    1. Differential diagnosis
    2. Evaluation
    3. Management
  2. Encephalopathy (acute, chronic)
    1. Toxic
    2. Metabolic
  3. Aphasia, apraxia
9. Disorders of consciousness
  1. Syncope
  2. Epilepsy
    1. Generalized at onset seizures
    2. Simple partial seizures
    3. Complex partial seizures
    4. Treatment
      1. Medical management with anticonvulsant medications
      2. Surgical management
      3. Vagal nerve stimulator
  3. Recognition and treatment of increased intracranial pressure
  4. Stupor and coma
    1. Toxic, metabolic
    2. Structural disease
    3. Herniation syndromes
  5. Brain death
10. Headache
  1. Migraine and variants
  2. Cluster headache
  3. Tension-type headache
  4. Headache associated with a structural lesion
  5. Benign intracranial hypertension (pseudotumor cerebri)
  6. Chronic daily headache
  7. Emergent headaches
    1. Subarachnoid hemorrhage
    2. Meningitis
    3. Giant-cell arteritis/temporal arteritis
11. Brain tumors
  1. Anterior or posterior fossa
    1. Primary
      1. Benign
      2. Malignant
    2. Metastatic
12. Infections (meningitis and encephalitis)
  1. Bacterial
  2. Viral or retroviral (human immunodeficiency virus)
  3. Fungal
  4. Tuberculosis
  5. Prion disease
13. Spinal cord disorders
  1. Anatomy and localization
  2. Extrinsic compressive lesions
  3. Intrinsic lesions
14. Sleep disorders
15. Disorders of peripheral nerve, neuromuscular junction and muscle
  1. Muscular dystrophy
  2. Peripheral neuropathy
  3. Mononeuritis multiplex
  4. Myopathy
  5. Guillain-Barre syndrome
  6. Myasthenia gravis
  7. Plexopathy
  8. Radiculopathy
  9. Diagnostic studies (e.g., nerve conduction velocity, electromyograph, muscle biopsy)
16. Congential disorders
  1. Brain and spinal cord malformations
    1. Arnold-Chiari malformation
    2. Meningomyelocele
    3. Cortical malformations
17. Chromosomal abnormalities, (e.g., Down's syndrome)
18. Abnormal head growth
  1. Microcephaly
  2. Macrocephaly (including hydrocephalus)
19. Aberrant development
  1. Development delay
  2. Mental retardation
  3. Neurodegenerative diseases
20. Developmental disorders of higher cerebral function
  1. Mental retardation
  2. Developmental language disorders
  3. Learning disabilities (e.g., dyslexia)
  4. Attention deficit disorder, with or without hyperactivity
  5. Pervasive developmental disorders (e.g., autism)
21. Psychiatric disorders mimicking neurologic disease
  1. Non-epileptic spells (e.g., pseudoseizures)
  2. Dementia of depression (e.g., pseudodementia)
  3. Conversion disorder
  4. Malingering
  5. Disorders of somatization and hypochondriasis
Principles of pain management
1. Pharmacologic agents
2. Surgical management
The psychologic and rehabilitation aspects of patient management, especially for chronic or long-term neurologic conditions
The genetic basis of certain neurologic disorders as they affect the patient and family and education of the family regarding the benefits of genetic counseling
An understanding of the neurologic disabilities of elderly patients, and the importance of assessing, restoring and maintaining their functional capacity (see also the Curriculum Guidelines for Care of Older Adults)
Neurologic complications of systemic illness
Prevention of neurologic disease

Skills

Evaluation skills
1. Recognizing and defining the neurologic problem
2. Taking a history and performing a complete neurologic and mental status examination, Glascow coma scale and pediatric developmental exam
3. Using clinical knowledge to localize the lesion and generate a differential diagnosis
4. Assessing the acuity and prognosis of the clinical problem as it relates to the need for immediate management and the requirement for expert assistance
5. Formulating a rational plan of further investigation and management
6. Knowing the indications, contraindications, risks and significance of ancillary tests
  1. Lumbar puncture and its performance
  2. Electroencephalogram
  3. Visual, brain stem auditory and somatosensory evoked potentials
  4. Nerve conduction study and electromyography
  5. Muscle and nerve biopsy
  6. Computed axial tomography with and without contrast
  7. Magnetic resonance imaging with and without contrast
  8. Magnetic resonance angiography
  9. Angiography
  10. Myelography
  11. Carotid ultrasound
  12. Sleep study
  13. Genetic testing
  14. PET scanning
  15. SPECT scanning
Management skills
1. Formulating a diagnostic and management plan and assessing the need for expert advice with an awareness of the risks, benefits and costs of this evaluation
2. Understanding the role of a neurologic specialist and the implications of special testing in patients with neurologic disease and the implications to the patient of test results
3. Managing the prevalent and treatable conditions listed above under "Knowledge," with consultation as appropriate
4. Managing emergent neurologic problems and obtaining urgent consultation when appropriate, including:
  1. Stroke
  2. Coma
  3. Meningitis and Encephalitis
  4. Status epilepticus
  5. Central nervous system trauma
  6. Increased intracranial pressure
  7. Acute visual loss
  8. Rapidly progressive neurologic deficit
  9. Neurologic respiratory failure
  10. Acute weakness
  11. Altered mental status
Managing the family and psychosocial issues that accompany the long-term care of patients with debilitating neurologic conditions, including home and community care, the utilization of community resources, the use of a multidisciplinary team and the primary role of the family physician as coordinator of long-term care
Continuing awareness of potential drug interactions and adverse drug effects, especially in elderly patients

Implementation

Implementation of these curriculum guidelines is best achieved within the capabilities of the particular residency program and at the discretion of the residency director. The resident must have the opportunity to diagnose and manage, under supervision, patients with neurologic disorders as well as those with signs and symptoms possibly referable to the nervous system, with emphasis neurologic consultation should supplement the educational process in the care of patients with problems referable to the nervous system.

Resources

Merritt, H.H., and Rowland, L.P. 2000 Textbook of Neurology. Tenth Edition. Philadelphia, PA: Lippincott, Williams and Wilkins.
Victor, M., et. al.. 2000. Adams and Victor’s Principles of Neurology. Seventh Edition. McGraw-Hill.
Bradley, W.G. et al., 1999 Neurology in Clinical Practice. Third Edition. Butterworth-Heinemann.
Patten, J., 1996 Neurological Differential Diagnosis, Second Edition. Springer.
Samuels, M.A. 1999 Manual of Neurologic Therapeutics. Sixth Edition., Lippincott, Williams & Wilkins.
Weiner, W.J., Goetz, C.G. 1999 Neurology for the Non-neurologist. Fourth Edition. Lippincott, Williams & Wilkins.
Wilkinson, J.L. 1998 Neuroanatomy for Medical Students. Third Edition. Butterworth-Heinemann.
Kandel, E.R., et al. 2000 Principles of Neural Science. Fourth Edition. McGraw-Hill.
DeJong, R.N., Mcgee, K.R. 1992 The Neurologic Examination. Fifth Edition. Harper & Rowe.
Gelb, D.J. 1995 Introduction to Clinical Neurology. Butterworth-Heinemann.
Plum, F., Posner, J.B. 1980 The Diagnosis of Stupor and Coma. Third Edition. F. A. Davis & Co.
Simon, R.S. et al. 2000 Clinical Neurology. Fourth Edition. Lange Medical Books, McGraw Hill.