neuro

DC Inst – Vasovagal Syncope

DC

You have been evaluated in the Emergency Department today for your syncopal episode. Your evaluation did not show evidence of medical conditions requiring emergent intervention at this time, however we recommend you follow up with your primary care provider for further testing as an outpatient.

Please follow up with your primary care doctor in 2-3 days.

Return to the ER immediately for worsening or uncontrolled symptoms, headache, chest pain, shortness of breath, persistent vomiting, vision changes, recurrent fainting, or for any other concerning symptoms.

Thank you for choosing us for your care.

DC Inst – Seizure

DC

You have been evaluated in the Emergency Department today for a seizure. Your evaluation, including labs and a CT of your brain, were unremarkable. Do not drive until you are cleared by a physician.

Please follow up with your primary care physician within two days. Call 1-800-825-2631 to schedule an appointment with a primary care physician.

Return to the Emergency Department if you experience recurrent seizures, difficulty walking or moving your arms or legs, slurred speech, difficulty with normal activities, abnormal behavior, vision changes, or for any other concerning symptoms.

Thank you for choosing us for your care.

DC Inst – Head Injury (CT)

DC

You have been evaluated in the Emergency Department today for your head injury. Your CT scan did not show signs of bleeds or fractures in your head.

We recommend you take 600mg ibuprofen every 6 hours or tylenol 650mg every 6 hours as needed for pain. If needed, you can alternate these medications so that you take one medication every 3 hours. For instance, at noon take ibuprofen, then at 3pm take tylenol, then at 6pm take ibuprofen.

Please schedule an appointment for follow up with your primary care physician as soon as possible.

Return to the Emergency Department if you experience worsening or uncontrolled pain, vision changes, recurrent vomiting, difficulty with normal activities, abnormal behavior, difficulty walking, numbness, weakness, or any other concerning symptoms.

Thank you for choosing us for your care.

DC Inst – Headache

DC

You have been evaluated in the Emergency Department today for headache. Your evaluation did not show evidence of medical conditions requiring emergent intervention at this time, and your pain improved with medication in the ED.

We recommend you take 600mg ibuprofen every 6 hours or tylenol 650mg every 6 hours as needed for pain. If needed, you can alternate these medications so that you take one medication every 3 hours. For instance, at noon take ibuprofen, then at 3pm take tylenol, then at 6pm take ibuprofen.

Please follow up with your primary care physician within two days.

Return to the Emergency Department if you experience worsening or uncontrolled pain, vision changes, recurrent vomiting, difficulty with normal activities, abnormal behavior, difficulty walking, numbness, weakness, or any other concerning symptoms.

Thank you for choosing us for your care.

DC Inst – Dizziness

DC

You have been evaluated in the Emergency Department today for dizziness. Your evaluation suggests that your symptoms are most likely due to peripheral vertigo.

You have been prescribed meclizine to help relieve your symptoms. Please take your prescription as directed. You can also try Epley Maneuvers at home to help relieve your symptoms- instructions are available online.

Please follow up with your primary care doctor in 2-3 days.

Return to the ER immediately for worsening or uncontrolled symptoms, worsening headache, chest pain, shortness of breath, persistent vomiting, vision changes, fainting, or for any other concerning symptoms.

Thank you for choosing us for your care.

SYNCOPE – Admit

MDM

This *** patient presents with symptoms consistent with syncope, most likely due to ***. Differential diagnosis includes ***reflex syncope (i.e. vasovagal syncope). Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding diatheses. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: ***). However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry.

Plan: labs, troponin, CXR, EKG, serial reassessment

STROKE – Code Activation

MDM

This *** patient presents with symptoms concerning for acute CVA versus TIA.***. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd’s paralysis. However, presentation most concerning for a CVA. EKG without evidence of STEMI or ischemia, fingerstick BS not hypoglycemic, and clinical picture does not suggest other stroke mimic. Plan to workup for acute CVA / TIA.

Plan: Code stroke protocol, MRI/MRA stroke protocol, stroke labs, Neurology stroke consult

SEIZURE – General

MDM

This patient presents with symptoms consistent with acute seizure, most likely due to ***. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. Presentation not consistent with non-epileptic type seizure to include syncope, neurologic etiologies (vertebrobasilar insufficiency, movement disorder, migraine), impact seizure related to head trauma.

Plan: BZDs, labs***, CT brain***, seizure precautions, Neurology consult***, reassess

Pearls

Consider nonconvulsive status: persistent change in behavior that lasts 30 minutes after a seizure. Look for positive symptoms (twitching, eye deviation, jerking) and negative (aphasia, catatonia, mutism). Many patients will just not respond. Think about this in head trauma patients with a decreased GCS and a negative initial CT. Also consider this in a “septic” altered patient with a borderline positive UA that isn’t that convincing.

PARESTHESIAS – Lo Risk

MDM

This *** patient presents with paresthesias, most likely due to ***. Differential diagnoses includes ***. Presentation not consistent with emergent neurologic etiologies to include brain / spinal cord nerve root or nerve problem given history & physical. Presentation not consistent with immune phenomenon to include GBS or vasculitis. Presentation not consistent with toxins to include botulism, diptheria, tick-borne illnesses, heavy metal poisoning. Presentation not consistent with acute drug toxicity or metabolic issues.

Plan: labs***, CT brain***, supportive care, reassessment