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At the heart of general practice since 1960

Five-minute Practitioner: August 2006

Driving

the basic dvla rule for group 1 drivers is for a one-year break from driving followed by a medical review before reissuing the licence. This applies to all epileptic seizures regardless of type, including auras, warnings and myoclonic jerks, and is regardless of whether or not the person remains conscious. For their licence to be returned, the patient must comply with the advised treatment and check-ups for epilepsy.

Changing or stopping medication is a fraught issue for patients who have recovered their licences. The DVLA advice is that the driver should not drive during the period of withdrawal and for six months afterwards.

Following a stroke or transient ischaemic attack (TIA), a driver is not permitted to drive for one month. If there are no residual neurological deficits at one month after the stroke, there is no need to notify the DVLA, otherwise the DVLA must be notified by the patient. Multiple TIAs over a short period of time ‘may require three months freedom of further attacks' and notification of the DVLA.

If the patient ignores the DVLA or doctor's advice, disclosure of personal information without consent may be justified where failure to do so may expose the patient or others to risk of death or serious harm. More »4

Migraine

any episodic disabling headache can be given a default diagnosis of migraine, but patients answering ‘yes' to two or three of these questions can be given a migraine diagnosis:

• Has a headache limited your activities for a day or more in the last three months?

• Are you nauseated or sick to your stomach when you have a headache?

• Does light bother you when you have a headache?

A caution with acute medications is

the potential for overuse and the development of chronic daily headache, which is particularly difficult to treat. Patients should be advised not to use acute medications on more than two days per week, and those suspected of overuse should be called in for review.

Suitable patients for prescribed preventive treatments are those with frequent, high-impact migraine attacks (more than four per month); those using an increasing number of symptomatic drugs (more than two days per week); those for whom acute medications are ineffective or precluded by safety concerns (perhaps due to co-morbidities); and those for whom one drug can be used to treat both the headache and a

co-morbidity. In addition, preventive medications should be given to all patients with chronic daily headache and cluster headache. Clinical evidence favours the use of a beta-blocker or the neuromodulator topiramate as first-line preventive treatments. More »13

Scoliosis

most patients with a curve in their spine present in adolescence. classically, the

patient is a tall teenage girl with a thoracic curve convex to the right. A patient presenting with a relatively minor curve at the end of her adolescent growth spurt can usually be reassured, but a

well-established curve in a younger child is more alarming and such patients need to be followed-up regularly.

As the child grows taller the curve tends to become more severe. It will not spontaneously resolve, but once the patient reaches skeletal maturity (in girls this occurs about 24 months after the menarche) the curve will stop progressing. The management is therefore to watch and wait. Patients who appear to be developing very severe curves should be selected out and considered for surgery.

Adolescent scoliosis is not normally painful and children in particular do not normally invent the symptom of back pain. The pain of osteoid osteoma is characteristically worse at night and relieved by aspirin. Any evidence of altered neurology or de-compensation requires urgent referral. More »40

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