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
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.
- 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
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
|Circulation x 4 extremities|
|Easily Reversible causes
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
- 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
|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,
|Traumatic Causes (Fractures)||Numbness/paralysis below the fracture||Stabilization, Acute decompression|
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|
|Time course of symptoms
|Events surrounding onset||
|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.|
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
|Cranial Nerves||Only document the CN you actually test. People rarely test all 12!
|Strength||Test all 4 extremities
|Sensation to light touch
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.
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
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
|How to Preform|
(Presenting with unconsciousness or upper extremity weakness)
(Presenting with lower extremity weakness)
(Presenting with unconsciousness or decreased sensation/weakness of an extremity)
(Presenting with numbness of the hands)
(Presenting with blindness)
|Patients with psychogenic blindness have a hard time not responding to visual stimulus.
Use your hand to mimic and object coming toward the patients face. Patients with non-organic blindness will typically blink or react.
Surprise the patient with a mirror. They have a hard time not adjusting their eyes to focus on their face.
Play a video of an optokinetic drum. If the patient has nystagmus their vision is intact.
(Presenting with numbness/weakness of the extremities)
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.
- 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.