The assessment and management of neurological symptoms presents a particular challenge in the community, as the differential diagnosis may be wide and include potentially serious conditions. Whilst the practitioner may commonly encounter conditions such as stroke and the fitting patient, all patients will require careful assessment to avoid the pitfalls of missing a serious underlying diagnosis. Headache presents a particular diagnostic difficulty where the cause may range from the benign, to the life-threatening subarachnoid haemorrhage. Some neurological symptoms may be non-specific but indicate the possibility of rare conditions requiring urgent investigation and treatment. This first article will cover the primary survey positive patient including the unconscious patient, the fitting patient, and those patients presenting with headache as their main symptom. The second article will cover frequently encountered neurological symptoms and signs to enable the practitioner to develop a safe and comprehensive system to decide which patients need immediate treatment and/or referral and which may safely be treated at home.

THE PRIMARY SURVEY POSITIVE PATIENT

All patients should be assessed according to ABC principles in order to identify any immediately life-threatening conditions.

Neurological conditions can be immediately life threatening by causing an ABC problem:

• Airway obstruction/compromise – loss of protective airway reflexes due to coma.

• Breathing difficulty/inadequacy – apnoea due to conditions affecting the respiratory centre–for example, brainstem stroke, intracerebral haemorrhage; respiratory muscle weakness–for example, Guillain Barre, myasthenia gravis

• Circulatory compromise – septic shock secondary to CNS infection, hypertension, and bradycardia in patients at imminent risk of coning.

The two main categories of immediately primary survey positive patients seen by the community practitioner are the unconscious …