Neurological Complaints

[mauricekenter]

I have had a string of patients with neurological complaints in which I don't know if I am working them up too much or not enough. I don't want to be the guy who either admits all neuro complaints or the one missing strokes!

Here are some examples:

1) 70 year old male with HTN and hyperlipidemia came in at 2am for chronic right shoulder pain worsening that evening, but also woke up with right facial numbness lasting <10 minutes (wife wanted him to go to the ER incase it was a stroke). Guy is more worried about his shoulder and neuro exam completely normal. Shoulder only hurts with ROM. Head CT is normal.

2) 35 year old male sent from PCP's office because patient states "she wanted to cover-her-ass" after he showed up with right handgrip weakness. Patient is vague and says it he can't remember when it started, but might have been yesterday. His right hand is noticeably weaker, but everything else normal and he has absolutely no medical history (not really a lacunar - clumsy hand syndrome-ish). Patient is annoyed he was sent by EMS to the ER from the office just for this complaint.

With all of these...arm/face numbness, tingling, vague neuro complaints how do you sort them out and decide on whether you work them up? Do you ever get a head CT and then if normal send home? I feel this is dangerous because you have entertained the idea of a stroke and haven't fully worked it up with an MRI, which I feel would be hard to defend in court if something happened.

Thanks in advance!

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[future_dr_house]

The first case sounds like tia. Admit all day every day in a 70 year old.

For the second case where did you localize the lesion? Is it peripheral or central? If you can't tell then admit for the mri. If you can demonstrate it's peripheral then d/w neuro and outpatient follow up.


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[WilcoWorld]

The first case sounds like tia. Admit all day every day in a 70 year old.

For the second case where did you localize the lesion? Is it peripheral or central? If you can't tell then admit for the mri. If you can demonstrate it's peripheral then d/w neuro and outpatient follow up.


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Funny - I'm much less worried about CVA in the 1st patient than in the 2nd.

Abnormalities of skin sensation don't worry me much unless they're associated with something else. However, loss of motor function is a big red flag for me. If someone has demonstrable motor weakness, my workup will continue until I have a negative MRI or a Neuro consult - sometimes this means admitting the patient. The exception being an obvious Saturday Night Palsy or something like that.

 

[e30ftw]

it all depends on your comfort with risk. No matter how squirrely the patient seems or how little the symptoms fit with stroke, something bad could happen to them later on in life and if you didn't do the MRI you could be liable.

I can tell you working with different attendings during residency (stroke center) some would get a head ct on both and discharge them if negative. some would push to admit both for mri/neuro. I'd argue that the young guy would probably be safe for DC if you ct/cta r/o dissection but if he had persistent neuro symptoms many ED physicians would admit him.

at my place we don't do stroke MRI's and neuro consults in ED so all these get admitted. The old guy is here for his shoulder not his face, if you tell him "there's a small chance we could be missing a small TIA and you would need MRI/neuro" and the guy would say, "no I want to go home." then you document that and he goes home w/ PMD f/u, ASA etc.

 

[GeneralVeers]

We simply can't MRI everyone with a vague neurologic complaint. In both of these patients I probably would not admit or MRI.

Pt #1 - Facial numbness by itself I am not worried about. The shoulder pain is definitely not stroke-related. I might do a head CT and D/C with neuro follow-up.

Pt #2 - Isolated one extremity weakness with no other symptoms is almost certainly peripheral. Can you prove it? No, but close neuro f/u with return for ANY worsening of symptoms would be defensible.

 

[The White Coat Investor]

We simply can't MRI everyone with a vague neurologic complaint. .

Why not? Many places/people admit every stupid little chest pain to reduce liability. How different is that from doing a bunch of MRIs? I assure you my hospital administration would very much support the idea of MRIing every vague neurologic complaint. Certainly if I have any concern at all that there might be a real neurologic lesion, I don't hesitate for a second to call the MRI tech in and get an MRI. I practically can't get a neurologic consultation by phone without having done at least an MRI, if not an MRA head and neck and maybe even an MRV head!

 

[GeneralVeers]

Why not? Many places/people admit every stupid little chest pain to reduce liability. How different is that from doing a bunch of MRIs? I assure you my hospital administration would very much support the idea of MRIing every vague neurologic complaint. Certainly if I have any concern at all that there might be a real neurologic lesion, I don't hesitate for a second to call the MRI tech in and get an MRI. I practically can't get a neurologic consultation by phone without having done at least an MRI, if not an MRA head and neck and maybe even an MRV head!

Simple time constraints. In my shop if I'm contemplating admitting a patient for MRI, the hospitalists demand that it be done in the ED first. I have no choice on this. Each MRI takes 2-3 hours to do, which means that a maximum of 10-12 MRIs per day. If you figure that outpatient, or inpatient non-emergent studies will use up 5-6 of those, then you can see the problem. There simply are not enough open slots to MRI every 20+ female with tingling in her fingers.

 

[Groove]

1) Smells like a TIA. Elderly. ABCD2 score is likely 3+. Easy admission and evidence is replete with studies showing reduced 90d stroke with pt's admitted for TIA work up, risk stratification, reduce risk factors, etc.. It's not unreasonable to send some of these home but I'd make sure they have stat follow up and I'd also consult neuro. There's a study that showed 1d vs 3d followups for these and it sig reduced the 90d stroke risk also. So, the sooner they are seen the better. I'd never discharge them unless they were comfortable with that plan and did not want admission. Still, I admit almost all of my TIAs.

2) Not enough info. Neck pain? Cervical radiculopathy? Median nerve entrapment? This smells less like a stroke from what you've described, and gut says probably would end up sending this guy out but if you can't explain the deficit after a thorough neuro exam, then don't d/c. I'd keep working them up. If it takes an MRI, then so be it. If MRI is going to delay things adversely, then consult neuro, discuss it, perhaps scheduling as outpatient wouldn't be unreasonable. I'd feel better if it was chronic and not a sudden/new deficit. If it's an abrupt and new motor weakness deficit, that worries me.

Conversion disorder pt's are another frustrating subset that I sometimes end up admitting.

 

[Birdstrike]

Okay, I call BS on all of you. Why wouldn't you admit and work these people up?

#1 Iffy story but old with risk factors. Much more to be lost if he wakes up next tues unable to speak or walk. Because he's old, retired, has nothing better to do tonight and realizes he's 70 and anything could happen at any time, he's cool with staying, as are his wife and daughter. Prediction rules and risk scores are worthless in hindsight. So is feel good talk of "saving costs for the system." Ct, labs, admit. No question about it. Hospitalist or Neuro whines for a few seconds. Tough s---. It's your job. Plus, you owe me for the BS chest pain/migraine I didn't call you on last week. Next!

(PS- Shoulder pain, with Neuro complaint and HTN history could be a dissection with embolus, by the way. Another reason to not blow off.)

#2 Iffy story, and doesn't have risk factors but if wrong, and it turns out there's some weird AVM, hyper-coagulable state, cocaine use or other unexpected joojoo and she wakes up unable to speak or move half her body after 6 hours of sleep, you're the big loser now, that tried to "save resources" with a drooling dysfunctional mother of two who's got at least one cousin who's a lawyer or knows a lawyer. Ct labs, admit. Let someone else diagnose: "Crazy." Advise patient she's probably fine but if she wants to be 100% sure, she's got to stay overnight. Politely explain that if she wants to leave that's cool too, but it's your job to explain the risks. Her choice her risk. Patient appreciates the honesty decides to take her chances and signs your AMA form. Chart says patient informed of risk of impending stroke, disability, death..." Or she chooses admit. Either way; no harm, no foul.

Especially considering those people with their names on those textbooks you've got will take money to testify that everything you did wrong? Work up, admit. Work up, admit. Work up admit. All day long.

Bread and butter. Swing. Ball out of park. Another win for Birdstrike.

 

[Arcan57]

1. Admit all day, every day.

2. Does it localize to a peripheral nerve distribution? If yes, d/c home. If no, admit.

 

[Doctor Bob]

Patient is annoyed he was sent by EMS to the ER from the office just for this complaint.

Have a discussion with the patient about risks/benefits of staying for further workup versus going home and following up. When the patient opts for going home, document the discussion and discharge.

 

[GeneralVeers]

If I'm going to discuss the case with neuro, then I just go ahead and get the MRI. The only guidance I ever get from neuro is "get an MRI", so if I even contemplate calling I just order it so as not to waste time.

Seriously, the young person with the peripheral neuropathy can be D/C home. Just document as such and do it.

 

[RustedFox]

Hahaha.

Had another attending tell me this about patients with 'vague neuro stories': Young women have vague neuro symptoms, get diagnosed with anxiety, and get placed on SSRIs. Old women have vague neuro symptoms, get diagnosed with TIA, and get placed on plavix.

 

[Birdstrike]

Young women have vague neuro symptoms, get diagnosed with anxiety, and get placed on SSRIs.

Definitely correct, most of the time. But every once in a while one of those will turn out to be MS (admittedly not many). Maybe not always an ER diagnosis, but...just sayin'.

I prefer the, "Non-specific paresthesia. F/u with Neuro for further evaluation" diagnosis personally. If it ends up being psych: no harm, no foul. If it ends up being MS or something otherwise more serious, you may have saved them a years worth of burning myelin and a years worth of being assumed cray-cray. (Happened to a family member, actually.)

 

[mauricekenter]

Thanks for all the replies. So as for the old guy, I basically got a CT head which was normal, told him it could have been a TIA and he didn't want to stay for workup. So he was discharged with an ASA daily and see his doctor in the AM for further workup. For the second case he has absolutely no other findings on exam. No neck pain, elbow pain, all reflexes fine, no FND, no vision issues, etc.

 

[The White Coat Investor]

Simple time constraints. In my shop if I'm contemplating admitting a patient for MRI, the hospitalists demand that it be done in the ED first. I have no choice on this. Each MRI takes 2-3 hours to do, which means that a maximum of 10-12 MRIs per day. If you figure that outpatient, or inpatient non-emergent studies will use up 5-6 of those, then you can see the problem. There simply are not enough open slots to MRI every 20+ female with tingling in her fingers.

If you are willing to order 5 more MRIs a day as an ED, your hospital is willing to buy another MRI machine I assure you. It might be different in a VA/Military situation (we literally ran the MRI 24/7 in the military- people were given 3 am appointments) but those aren't money losers.

P.S. You need new MRI techs too. 2-3 hours is way too long.

 

[Cheese Whiz]

Question for those of you saying dc with close neuro follow ups: are you just listing a neurologist on the DC paper and documenting advised to f/u next day or are you physically calling the neurologist to set up f/u for pt?

 

[Arcan57]

Depends on the neurologist on-call. One group of neurologists see outpatients very quickly but if you call them they usually want to admit the patient for their MRI scan as an overprotective medicolegal thing. The other group will open urgent appointments but a call from a patient means an appointment 3-4 weeks off.