Neuro

Altered Mental Status

Rapid Review

  • Differentials
    • “AEIOU-TIPS”
      • Alcohol
      • Electrolytes, Endocrine, Encephalopathy
      • Infection
      • Overdose
      • Uremia
      • Trauma
      • Insulin
      • Poisons, Psychogenic
      • Stroke, Seizure, Space occupying lesion, Shock
  • History
    • Baseline mental status
    • Last seen normal
    • Recent trauma
    • New medications/exposures
    • Recent surgery/illness
    • Additional symptoms
  • Physical Exam
    • Signs of trauma
      • Consider concussion, brain bleed
    • Pupil size
      • Consider overdose, ICP
    • Neck stiffness
      • Consider meningitis
    • Odor
      • Consider DKA, alcohol
    • Neurological deficits
      • Consider stroke, seizure
    • Abnormal lung sounds
      • Consider pneumonia, heart failure, COPD
    • Skin lesions
      • Consider infection
  • Work-Up
    • Labs:
      • CBC, CMP, UA, blood alcohol level. 
      • Consider: urine drug screen, TSH, lactate, ABG, blood cultures, lumbar puncture
    • Imaging:
      • CXR
      • Head CT

Pearls

  • Be careful attributing mental status changes to underlying cognitive disorders (ex. dementia). Take a detailed hx and listen to friends/family to see if there is a change in baseline.
  • Infection is a commonly missed source of AMS. Always examine the urine, lungs, and skin on undifferentiated patients.  
Video Credit: Anna Pickens

Headache

Rapid Review

  • Differentials
    • Most serious
      • Meningitis
      • Subarachnoid hemorrhage
      • Temporal arteritis
      • CVA
      • Cervical artery dissection
      • Venous Sinus Thrombosis
    • Most Common
      • Tension headache
      • Migraine headache
      • Sinusitis
  • History
    • Worst headache of life
      • Consider dissection, CVST, SAH
    • Neck stiffness
      • Consider meningitis, brain abscess
    • Sick contacts
      • Consider carbon monoxide poisoning, meningitis
    • Vertigo
      • Consider stroke, vertebral artery dissection
    • Confusion
      • Consider encephalitis, CVST, mass
    • Visual Changes?
      • Consider mass, glaucoma, temporal arteritis
    • Head Trauma
      • Consider intracranial bleeding, concussion
  • Physical Exam
    • Head trauma
      • Consider intracranial bleeding, concussion
    • Dilated pupil
      • Consider acute glaucoma, brain injury
    • Photophobia
      • Consider migraine, meningitis
    • Kernig/Brudzinski Sign
      • Consider meningitis
    • Rashes/lesions
      • Consider meningitis
    • Neurological deficits
      • Consider cervical artery dissection, space-occupying lesion
  • Work-Up
    • Labs
      • CBC, BMP, ESR, blood cultures
      • Lumbar puncture for CSF analysis
    • Imaging
      • Head CT w/o contrast (if suspect cerebellar stroke
      • MRI brain w/o contrast (if CT negative)
      • CTA of head/neck (if suspect dissection)

Pearls

  • Always inquire about the onset and time to maximum intensity in these patients. In general, benign etiologies are typically gradual whereas life-threatening causes, such as subarachnoid hemorrhage, will be rapid in onset. 
  • When in doubt about meningitis, just do the lumbar puncture!
Video Credit: EM in 5

Syncope

Rapid Review

  • Differentials
    • Cardiac
      • Arrhythmias (WPW, Brugada, VF/VT, AV block)
      • Aortic stenosis
      • Aortic dissection
      • Pulmonary embolism
    • Reflex
      • Vasovagal 
      • Carotid sinus syndrome
      • Orthostatic hypotension
    • Neuro
      • Stroke
      • Seizure
    • Pulmonary
      • Pulmonary embolism
      • Pneumothorax
    • Genitourinary
      • Ectopic pregnancy
    • Gastrointestinal
      • Upper/lower GI bleed
  • History
    • Head trauma before or after episode
      • Consider brain hemorrhage
    • Tonic/clonic movements, tongue biting, urinary incontinence
      • Consider seizure
    • Recent emotional stress
      • Consider vasovagal syncope
    • Associated with exertion
      • Consider cardiac or vascular causes
    • Diabetic
      • Consider hypoglycemia
    • Melena or hematochezia
      • Consider GI bleed
  • Physical Exam
    • Head trauma
      • Consider intracranial hemorrhage
    • Murmurs, Rubs, Gallops
      • Consider aortic stenosis or heart failure
    • Capillary refill
      • Consider dehydration
    • Rales/wheezing in lung fields
      • Consider heart failure
    • Neurologic deficits
      • Consider stroke
    • Tongue bite marks
      • Consider seizure
  • Work-Up
    • EKG
      • Look for ischemia, arrhythmia, delta wave, long QT, etc.
    • Labs
      • CBC, BMP, hCG
    • Imaging
      • CXR 
      • Head CT w/o contrast

Pearls

  • Syncope and “near syncope”  have the same basic pathophysiologic causes and should be worked up the same.
  • Cardiac sources of syncope carry significant morbidity and mortality. All patients with syncope should have an EKG performed and be on continuous monitoring until cardiac etiology has been ruled out. 
Video Credit: Anna Pickens

Dizziness

Rapid Review

  • Differentials
    • Vertigo
      • Benign Positional Peripheral Vertigo
      • Labrynthitis
      • Meniere Disease
      • Cerebellar stroke
      • Vertebral basilar artery insufficiency
      • Brain tumor
      • Multiple sclerosis
    • Lightheadedness
      • Anemia
      • Hypotension
      • Bradycardia
      • Dehydration
  • History
    • What do you mean by “dizzy”
      • Differentiate between vertigo and lightheadedness
    • Positional
      • Consider BPPV
    • Palpitations
      • Consider arrhythmia
    • Chest pain/SOB
      • Consider ACS/PE
    • Focal neurologic deficits (diplopia, dysarthria, dysphagia, dystaxia)
      • Consider cerebellar dysfunction
  • Physical Exam
    • Head Impulse Test
      • Abnormality suggests peripheral lesion
    • Nystagmus
      • Horizontal/vertical/rotary nystagmus suggests central lesion
    • Test for Skew
      • If unable to remain focused on spot, specific for central lesion
  • Work-Up
    • EKG
      • Useful for work-up of lightheadedness/pre-syncope
    • Labs
      • CBC, BMP, hCG
    • Imaging
      • CT or MRI (if concern for central lesion)

Pearls

  • Differentiating between vertigo, lightheadedness, and dizziness is not important from a diagnostic standpoint and is often described differently from patient to patient. Instead, focus your history on the timing of the symptoms (intermittent, continuous) and triggers (ex. head/body movement)
  • The HINTS exam is a vital physical exam maneuver for the work-up of dizziness/vertigo patients. Take the time to master it!
Video Credit: The Center for Medical Education

Seizure

Rapid Review

  • Differentials
    • Metabolic/Endocrine
      • Hypoglycemia
      • Hyperglycemia
      • Hyponatremia
      • Uremia
    • Medications
      • Antispasmodics
      • Anticholinergics
      • Antipsychotics
      • Antibiotics (isoniazid, fluoroquinolones)
    • Substance use
      • Alcohol withdrawal
      • Stimulants
      • Organophosphates
    • Infection
      • Meningitis
      • Encephalitis
      • Brain abscess
    • Structural
      • Intracranial hemorrhage
      • Hydrocephalus
      • Neoplasm
  • History
    • Type of seizure
      • Differentiate between generalized vs partial
    • Previous episodes
      • Consider hx of epilepsy
    • Head trauma
      • Consider intracranial hemorrhage
    • Drug/alcohol use
      • Consider alcohol withdrawal or drug toxicity
    • Diabetic
      • Consider hypoglycemia
  • Physical Exam
    • Head trauma
      • Consider intracranial hemorrhage
    • Tongue biting
      • Consider seizure vs syncopal episode
    • Rashes/lesions
      • Consider infectious causes
    • Pregnancy
      • Consider eclampsia
  • Work-Up
    • Labs
      • CBC, CMP, BAL, Urine drug screen
    • Imaging
      • CT head non contrast (if first seizure)

Pearls

  • Always check a blood glucose level on these patients. Hypoglycemia is a common and easily reversible cause of seizures.
  • HIV positive patients presenting with seizure should receive a head CT with IV contrast to rule out toxoplasmosis.
Video Credit: Details Medical