Focal Neurologic Complaint

Authors: Kili Grace O’Bryant, MD and Caroline Pace, MD, Department of Emergency Medicine, Medical College of Wisconsin

Editor: Matthew Tews, DO, MS, Department of Emergency Medicine and Hospitalist Services, Medical College of Georgia

Introduction

In Emergency Medicine, the “Focal Neurologic Complaint” (FNC) is a catch-all phrase for neurologic complaints that do not easily fit the pattern of other more commonly addressed neurologic emergencies, such as stroke, seizure, headache, back pain, meningitis, and altered mental status, that are seen frequently by emergency physicians. Commonly addressed neurologic emergencies have well-recognized presentation patterns, established work-ups and evidenced-based treatment plans.

Focal neurologic complaints can be vague including, difficulties with speech, vision, strength, sensation, balance, and coordination. There are few comprehensive reviews or guidelines educating Emergency Physicians on strategies to address FNC’s. There is a paucity of research guiding emergency care for most disease processes that result in FNC’s.

This article provides an overview to approaching the FNC in the emergency department setting. The regional complaint-based guide provided below aids in the development of a differential diagnosis.

Rather than memorizing this chapter, instead use it as a resource for developing your practice of assessing neurologic complaints and developing a differential diagnosis. The guides found in this chapter can be used when working in the emergency department or on the wards. Over time, you will develop a routine to approaching these complaints, you will form your own rapid neurologic exam, and it will become an easy part of your standard exam. Through repeated assessment of patients with FNC’s you will become familiar with the differential diagnosis for neurologic emergencies based on the region of complaints.

Objectives

  • Identify important aspects to taking a focused history of a neurologic complaint
  • Develop a rapid, thorough neurologic exam
  • Document appropriate neurologic exam findings
  • Obtain exposure to less common neurologic emergencies
  • Develop a differential diagnosis for a FNC

Initial Assessment and Primary Survey

Assess ABCDE’s

Initial assessment of all patients should start identifying life threatening conditions by assessing their Airway, Breathing, Circulation, Disability, and Easily Reversible Causes (ABCDE). If a problem is identified at any step in the initial assessment, it should be addressed prior to moving on to the next step. Disability, indicating their level of responsiveness, should be taken into account when deciding whether a patient can adequately protect their airway. A common mnemonic for evaluating this is AVPU (see table 1).  For example, if a patient were to vomit, would they be conscious enough to cough or roll to the side to protect their airway?

Table 1: Initial Assessment

Airway
Breathing
Circulation x 4 extremities
Disability

  • AVPUAlert, responsive to Verbal, responsive to Pain, Unresponsive
  • Document movement x 4 extremities
    • Following commands
    • Moving spontaneously
    • Withdrawals/localizes pain
Easily Reversible causes

  • Glucose, Narcan

If Intubating

If the patient requires intubation due to an airway or breathing issue, or altered mental status, perform a brief neurologic exam prior to intubating if time allows.

  • The brief neurologic exam ideally includes (at a minimum):
    • Mental Status
    • Pupils
    • Movement x4 extremities
  • Provides invaluable information to future providers and guides treatment
  • Do not compromise airway protection or oxygenation
  • If a neurologic exam is unable to be performed, document relevant observations.

Rule-out Time Sensitive Diagnoses

Initial assessment of the FNC should include ruling out time sensitive diagnoses that require time sensitive treatment.  Since a FNC can be due to emergent conditions, the following conditions should be evaluated and exclueded first.

**Acute onset of neurologic symptoms indicates need for acute treatment, until proven otherwise **

 Table 2: Time Sensitive Diagnoses 

Diagnosis Clinical Presentation Treatment
Acute Stroke Facial droop, unilateral weakness, Early TPA vs Intervention
Acute Intracranial Hemorrhage speech difficulties Blood Products vs Intervention
Recurrent/Status Seizure Recurrent seizures w/o return to baseline in between Antiepileptic’s, paralysis and sedation with Propofol
Infection (Meningitis/Encephalitis) Fever, HA, neck stiffness, AMS Early antibiotics/antivirals
Nerve compression (Cauda equina) Back pain, b/l leg weakness, urinary retention, stool incontinence Surgical decompression
Vascular Causes (Arterial dissection – carotid, thoracic, vertebral) Carotid – stroke like symptoms

Thoracic – chest pain and neurologic deficits

Vertebral – cerebellar findings

Heart rate and blood pressure control,

Vascular intervention

Traumatic Causes (Fractures) Numbness/paralysis below the fracture Stabilization, Acute decompression

History

FNC’s are often vague and have an insidious onset. Obtaining a rapid, focused history of the onset and symptoms can significantly help with development of a differential diagnosis. Patients may not be able to provide a reliable history due to the syndrome effecting their mental functioning, lack of awareness of their symptoms, or the prolonged time course of onset.

Table 3: Components of History of Present Illness for a FNC

Presenting complaint Localization of neurologic deficit
Associated symptoms Altered mental status, fever, headache, neck pain, chest pain, problems urinating
Patients baseline
  • Ask EMS or family
  • Call nursing home
Time course of symptoms

 

  • When was the last time they were normal?
  • Were the symptoms maximal at onset or have they progressed?
  • Are the symptoms constant or do they come and go?
Events surrounding onset
  • What were they doing when the symptoms started?
Recurrent symptoms
  • Has this happened before?
  • What was it the last time?
PMH, Recent trauma/illness PMH and recent changes in PMH, including illness or trauma
Medication history Anticoagulation, recent changes
Alcohol, Tobacco, Drugs Types and quantities of alcohol, tobacco, and drugs
Non-organic causes Recent life stressors, psychiatric history (personality disorder,) secondary gain.

Neurologic Exam

Completing a full neurologic examination is impractical in most clinical settings, including the emergency department. Developing a focused, yet thorough neurologic exam and understanding what each test evaluates will help immensely when evaluating neurologic complaints.

Table 4: Rapid Neurologic Exam Example

Elements Components
Mental Status
  • Alertness – AVPU
  • Orientation – person, place, time, and events
  • Altered Mental Status can mean many different things use specific terms such as:
    • Disoriented, confused, somnolent, unresponsive, strange behavior, abnormal emotion
Speech Rate

  • Normal, slow, pressured,

Rhythm

  • Stilted, slurred, word finding difficulty, inappropriate words
Cranial Nerves Only document the CN you actually test. People rarely test all 12!

  • Pupils PERRL (II,III)
  • EOMI (III,IV, VI)
  • Facial sensation and Masseter intact (V)
  • Face symmetric (VII)
  • Palate rise equal (X)
  • Shoulder shrug/Head turn (XI)
  • Tongue midline (XII)
Strength Test all 4 extremities

  • Upper extremities – grip strength and elbow flexion/extension
  • Lower extremities – ankle plantar/dorsiflexion and knee flexion/extension
  • Rate on scale 0-5
    • 0/5 – no contraction
    • 1/5 flicker
    • 2/5 not against gravity
    • 3/5 against gravity but not resistance
    • 4/5 against some resistance
    • 5/5 full strength
  • Equal bilaterally
Sensation to light touch

 

  • Hands and feet
  • Present/absent/decreased
  • Equal bilaterally
Coordination
  • Finger-to-nose, heal-to-shin
  • Romberg
  • Gait
    • Normal gait without assistance, steady gait but needs assistance, ataxia, walking to one side or the other
    • Gait should be tested at patient’s baseline ambulatory status. Therefore, if the patient walks with a cane or walker they should be tested with a cane or walker.

Occasionally you will need to expand your exam to do a more comprehensive assessment

  • More in depth exams should be focused based on
    • The neurologic complaint
    • Positive/negative findings found during a rapid exam.

Exam Documentation

 Detailed and accurate documentation will provide insight into the progression of a neurologic complaint over time and help direct care from consultants and other providers.  It is important to use consistent terminology and documentation components so that other providers have a shared understanding of what was found on exam.

It is helpful to develop a documentation phrase describing a normal exam. Save it in your documentation program so you can easily add it to a note. You can also use it to aid your memory about what an exam tests for (cranial nerve numbers, strength rating, etc.)

Table 5: Exam Documentation Example

Mental status: A+O x3, able to recount events

Speech: Normal rate and rhythm

CN: Pupils PERRL (II,III), EOMI (III,IV, VI), Facial Sensation and Masseter Intact (V), Face symmetric (VII), Palate rise equal (X), SCM and Trapezius Nl (XI), Tongue midline (XII)

Strength: 5/5 and equal bilaterally x 4 extremities

0/5 – no movement

1/5 – flicker

2/5 – not against gravity

3/5 – against gravity

4/5 – some resistance

5/5 – normal strength

Sensation: Intact to light touch and equal b/l x4 extremities

Coordination: Finger-to-nose and heal-to-shin intact, negative Romberg

Gait: Normal, walks without difficulty or assistance

Differential Diagnosis

The differential diagnosis for FNC’s is broad. It is important to start by ruling-out time sensitive diagnoses as discussed above (acute stroke, acute intracranial hemorrhage, recurrent/status seizures, infection, nerve compression, vascular causes, traumatic causes.) Below is a regional complaint-based guide briefly describing some of the more common focal neurologic deficits encountered in the emergency department. This is not a comprehensive list but provides a quick overview of the more common focal neurologic deficit presentations.

 

Distinguishing Organic from Psychogenic

Psychogenic cause of focal neurologic complaints is a diagnosis of exclusion. In the end, erring on the side of a neurologic origin until proven otherwise is wise.  Many experienced providers have been fooled by neurologic symptoms they felt were clearly psychogenic, only to discover the patient was found to have an organic cause for their symptoms.

Extreme care must be taken to ensure you are not harming the patient while preforming these exam techniques. Have a discussion with a trained provider as to when it is appropriate to use these tests. The first time you perform these tests, you should do it under the guidance of a trained provider. Findings concerning for psychogenic origin do not necessarily rule out an organic origin and a full evaluation must be complete before a final diagnosis is made.

Table 6: Tests to Assess for Psychogenic Etiology of FNC 

Test

(Indications)

How to Preform
Hand Drop

(Presenting with unconsciousness or upper extremity weakness)

  • Position the patient’s hand 6 inches over the patient’s forehead and let go.
  • Patients with true weakness are unable to keep their hand from dropping on their forehead.
  • Patients with psychogenic cause will often adjust so the hand drops to the side of their face
  • Care must be taken to make sure the patient does not get hurt
Hoover Sign

(Presenting with lower extremity weakness)

  • Place both hands under the patients heels and ask them to raise the affected leg straight up in the air.
  • Patients with organic cause should place weight on the unaffected extremity in attempt to raise the affected extremity.
  • Patients with psychogenic cause will place no weight on the unaffected extremity, indicating they are giving poor effort to the exam.
Painful stimulus

(Presenting with unconsciousness or decreased sensation/weakness of an extremity)

  • Using a hard object such as a pen or penlight, apply moderate pressure with the object to the junction of the patients nail bed and skin, pinching the nail bed between your fingers and the pen
  • This exam should not be done in a punitive way, but to determine the presence of a pain response in a patient with the complaint of loss of sensation in the extremity
Hand Sensation

 

(Presenting with numbness of the hands)

  • Have the patient extend both arms with thumbs down, cross the arms, and clasp their hands together. Test sensation of their fingers.
  • This is designed to help determine inconsistent answers regarding which side is insensate.
Functional

Blindness

(Presenting with blindness)

Patients with psychogenic blindness have a hard time not responding to visual stimulus.

  • Visual threat

Use your hand to mimic and object coming toward the patients face. Patients with non-organic blindness will typically blink or react.

  • Mirror test

Surprise the patient with a mirror. They have a hard time not adjusting their eyes to focus on their face.

  • Optokinetic Drum

Play a video of an optokinetic drum. If the patient has nystagmus their vision is intact.

Reflexes

(Presenting with numbness/weakness of the extremities)

  • Reflexes are involuntary and difficult to mimic.
  • The presence of reflexes indicates both sensory and motor pathways are intact.
  • The Babinski reflex can be irritating and should elicit a response.

Pearls and Pitfalls

  • Preform ABCDE’s and treat life threatening findings
  • Always rule out time sensitive diagnoses first
  • Obtain a rapid, focused history
  • Develop your own routine rapid neurologic examination
  • Document your exam findings clearly
  • Consider a broad differential diagnosis
  • Often, a formal diagnosis is not made in the emergency department, and outpatient referral is necessary.
  • Psychogenic causes of focal neurologic complaints are a diagnosis of exclusion.

References

  • Blumenfeld MD, Hal. “Neuroanatomy through Clinical Cases.” Sinauer Associates Publishers, Inc, 2010. neuroexam.com/neuroexam/. Retrieved 1 Feb 2018.
  • Goldstein JN, Greer DM. Rapid focused neurological assessment in the emergency department and ICU. Emerg Med Clin North Am, 2009;27:1-16.
  • Ingram MD, Michael. “3 minute neurologic exam.” YouTube, 1 Jan 2010. https://www.youtube.com/watch?v=fgwN1P5PDaA. Retrieved 1 Feb 2018.
  • Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill; 2016.