Getting the Most From Your History and Physical, Part 2: Neurological Patients

This is the second of a four-part series that will appear bimonthly. Find Part 1 at www.emsworld.com/12149999. Find an associated video primer on stroke detection for EMS at https://www.emsworld.com/12188313. 

You and your crew are dispatched to the home of an elderly woman who complains of weakness and dizziness. On arrival you find a single patient lying on a couch. She is awake and can answer questions. Now comes the hard part: How do you determine if this patient is just a little dehydrated, didn’t get enough sleep, or has a viral illness, vertigo, a heart attack or an acute stroke? Is this case a load-and-go or stay-and-play?

In this second installment of our multipart series, we will examine how to perform a neurological history and physical exam. Neurological emergencies present with a wide variety of symptoms. The ability to differentiate between them is necessary to determine a prehospital diagnosis with differential. Conducting a systematic neurological H&P will provide enough information to quickly and accurately make a determination regarding your patient care.

Included in this article is an introduction to the “pit crew” approach to prehospital medicine. Using the pit crew approach helps organize the prehospital crew into an efficient team with clear division of labor toward an overall goal of rapidly assessing, diagnosing, stabilizing and transporting the patient.

Neurological H&P

When assessing patients with neurological complaints, it is imperative to conduct a thorough baseline exam as soon as contact is made. Patients with neurological emergencies may have their mental status rapidly deteriorate, making it more difficult to assess for a stroke or gather reliable information that may assist in making a diagnosis.

The goal is to complete both the history and physical exam within 3–5 minutes. This will vary depending on the patient’s chief complaint and mental status. As always, patient stabilization and transport should not be delayed to conduct a lengthy history and physical exam.

A patient’s mental status is the most reliable indicator of brain function, so when there is altered mental status, obtaining a history and assessing for cerebellar function, weakness and paresthesia becomes far more difficult. For these patients observation, soliciting information from caregivers or witnesses, checking for medical alert bracelets or wallet cards, and utilizing diagnostic tools (such as vital signs, SpO₂, SpCO, EtCO₂, ECG [both II- and 12-lead] and glucose) may provide you with valuable information.

To be proficient in conducting the history and physical, your process must be organized and systematic. Practice makes perfect. Utilize the following outline as a guide for neurological assessments and a template for writing patient care reports.

Neurological history and physical exam outline:

1. Chief complaint—The main reason 9-1-1 was called;

2. History

• History of the present illness, including OPQRSTA
• Past medical history
• Medications
• Medication allergies
• Social history
• Family history; 

3. Review of systems—In general, when conducting a focused neurological exam, the following body systems should be reviewed, as they are most likely to provide the most information regarding neurological emergencies.

• General: Look for recent illness, fever/chills, petechial rash
• HEENT: Look for headache (worst headache of life), head trauma, changes in hearing, vision loss, blurred or double vision, photophobia
• Cardiovascular: Look for syncope, palpitations
• Neurological: Look for difficulty speaking or understanding speech, unilateral weakness, dizziness, seizure, paresthesia, difficulty with coordination, loss of balance;

4. Physical exam

• Vital signs
• Stroke assessment tool (Cincinnati, LAMS, MEND, etc.)
• Mental status
• Speech
• Cranial nerves
• Cerebellar function
• Motor function
• Sensory function;

5. Prehospital diagnosis and differential diagnosis.

Physical Exam

Before we discuss the specifics of a neurological exam, let’s consider the logistics of conducting a physical exam. Today many agencies have more than one paramedic on a unit. That’s both good and bad news. When more than one paramedic is on scene, often no one is in charge because everyone is in charge. This is confusing for the crew as well as the patient.

To bring some calm to the chaos, many agencies have adopted the “pit crew” concept. The pit crew is an organized team approach to patient care and an efficient way to utilize personnel in order to maximize care and minimize treatment and transport times. Beginning each shift, patient care responsibilities should be divided up among the crew. Responsibilities will depend on the number of personnel and their level of training (see sidebar).

Vital Signs

Stroke patients frequently present with a reflex hypertension. Emergently lowering the blood pressure can be harmful in an ischemic stroke since it will decrease cerebral perfusion to the ischemic brain, resulting in a larger stroke. However, hemorrhagic strokes may require a decrease in blood pressure to slow bleeding. A CT scan needs to be obtained prior to making a decision on blood pressure treatment. Therefore, treatment of stroke-associated high blood pressure is not generally something to be addressed in the prehospital setting.

Stroke Assessment Tool

In most scenarios the history comes first. However, when there is suspicion that a stroke alert may be present (based upon the caller’s chief complaint to dispatch), the need to obtain a stroke assessment within the first several minutes of patient contact trumps the need for obtaining history. Because “time is brain,” neurological exams begin with the stroke assessment tool adopted by your agency. Once a stroke is identified, rapid transport to a stroke center is more important than staying on scene to conduct additional neurological exams. More in-depth exams are warranted for stable patients whose initial stroke assessments are negative.

Portions of the following neurological exam may already be included as part of some stroke assessment tools. As an example, the Cincinnati Prehospital Stroke Scale (CPSS) includes speech, one cranial nerve and upper-body motor function but does not include vision, cerebellar, sensory or lower-body motor function. The CPSS may not identify less-common posterior or anterior cerebral artery strokes, as these require additional assessments of visual fields, cerebellar function, lower-extremity motor strength and sensory function. The key to any stroke assessment is identifying focal or unilateral findings. Bilateral findings that are symmetrical generally are not due to stroke. A patient who is unable to hold up either arm during the stroke assessment does not display a focal one-sided finding; therefore, this is not usually a sign of a stroke. Unilateral weakness is characteristic of a focal neurological disease such as a stroke.

A stroke generally involves the brain being affected by disrupted blood flow to a specific artery, and the territory that artery supplies will determine the symptoms. By testing extremity sensory and motor function, cranial nerves, speech and cerebellar function, you ensure each of the major branches of the CNS circulatory system gets tested. Some of the major prehospital stroke screens can’t pick up all strokes because not all of the individual blood vessel territories are evaluated.

For example, the Cincinnati Prehospital Stroke Scale, when used by paramedics in an urban EMS system, has been demonstrated to have a sensitivity of only 79%. This means 21% of strokes will be missed by the CPSS.¹ Because it is a far more complete exam, the authors recommend the use of the Miami Emergency Neurological Deficit (MEND) tool, which this article more closely tracks. By expanding the basic neurological exam, the paramedic can identify patients with less-common types of strokes who would otherwise have gone undiagnosed, resulting in a delay in treatment and loss of chance for improvement.

Mental Status Assessment

Mental status is the most important indicator of brain function. An altered mental status can occur suddenly or over several days and can range from mild confusion to coma.

• Is the patient alert? If not, are they responsive to verbal or painful stimuli, or are they unresponsive (AVPU)?
• Is the patient confused? Do they correctly follow commands? Do they know the month and their age? Look for inability to think clearly and disorientation to person, place or time.
• Does the patient exhibit signs of delirium (e.g., agitation, hallucinations, rambling, delusion)?

Unresponsive patients significantly hamper your ability to conduct an H&P. Gather as much history and information as you can from friends, family, bystanders, current medications and medical alert tags. The medication list can give the paramedic a clue to the patient’s past medical history. As an example, a patient taking strong blood thinners or an antihypertensive may have a problem with atrial fibrillation or hypertension, both of which are known major risk factors for stroke. The physical exam will have to be limited to vital signs, blood glucose levels, SpO₂, EtCO₂ and ECG. Additionally, a physical exam should look for signs of a seizure (oral trauma and incontinence), head trauma and the size and reactivity of the pupils (see Table 1).

Speech

Speech is an efficient neurological test since it evaluates many areas of the brain at once. It evaluates the ability to hear words, translate the words into meaning, create a thought to respond, and then transmit that thought via coordinated use of speech musculature. Aphasia and dysarthria are two indicators that speech pathways have been disrupted.

Aphasia is a patient’s inability to express him- or herself—e.g., speaking or writing sentences that make no sense, using unrecognizable or inappropriate words, speaking in short/broken sentences, difficulty comprehending spoken or written words, or misnaming objects. The most common causes of aphasia are stroke, traumatic brain injury, brain tumors and degenerative disorders of the brain.

Dysarthria, slurred speech, occurs when the muscles responsible for speech become weak. Causes include stroke, Bell’s palsy, TBI, brain tumors, neurological disorders such as multiple sclerosis and drug/alcohol intoxication.

To assess a patient’s speech, have them repeat a phrase such as “You can’t teach an old dog new tricks,” or alternatively ask them to count to 10. Then hold up a pen and ask, “What is this?” Anything other than the ability to clearly repeat the sentence and correctly identify the object is an abnormal response.

Cranial Nerve Assessment

Cranial nerves (CNs) are supplied by the posterior circulation of the brain. There are 12 nerves, but we routinely only test a fraction of them.

Visual fields, CN II (optic nerve)—This controls the ability to see. To test for isolated strokes in the visual cortex of the brain or retina, face the patient and have them focus on your nose while they cover one eye with a palm. Hold one or two fingers up to both sides of the patient’s face, where both of you should be able to see them in your peripheral vision. Ask the patient to identify how many fingers you’re holding up on each hand or, alternatively, wave your fingers and ask the patient if they can see your fingers move on both sides. Repeat the test on the other eye. Some strokes will cause loss of vision just to one side of the peripheral field, and the patient may not even notice the loss without being tested. Note any complaint of vision loss or blurred or double vision.

CN III (oculomotor)—Controls the pupil’s response to light and is one of several nerves that allow movement of the eyes. The pupils are better assessed if they are slightly dilated. Therefore, whenever possible, pupils should be examined in an area that is dim but not too dark to see the eyes. Have the patient look straight ahead and note the size and shape of the pupils and how they react in response to light. Normally both pupils should constrict together. Pupils that are equal, round and reactive to light are said to be PERRL.

Pupils should be of equal size (note size in mm). However, approximately 20% of the population has anisocoria (unequal pupil size). If both pupils respond to light, consider a pupil that is up to 1 mm larger than the other a normal variant.

• Normal pupil size varies depending on the amount of light. In general, under normal lighting conditions, the pupils range from 3–5 mm.
• Constricted (pinpoint) pupils of 1–2 mm are caused by bright light, opiates and other drugs.
• Bilateral dilated pupils are generally greater than 5 mm. Causes include low light, sympathomimetics, hypoxia/anoxia, CO poisoning, benzodiazepines and anticholinergic medications.
• A unilateral dilated pupil in a patient who is conscious and alert is often caused by atropine drops. Occasionally a brain tumor can cause this as well.
• A unilateral fixed and dilated pupil in an unresponsive patient is generally caused by increased intracranial pressure. This occurs when intracranial swelling compresses the third cranial nerve, which loses its ability to constrict the pupil.

CNs III, IV, VI (oculomotor, trochlear, abducens)—Controls extraocular movements of the eyeball. Instruct the patient to focus on your finger and not move their head. Holding your finger at eye level and about a foot in front of the patient’s face, move the finger to each side and note how the eyes track it. The eyes should track smoothly, without saccades (a jerking of the eyes), and should be able to move freely all the way to each side. Lack of ability to move the eyes to one side of the body is known as a gaze preference and is a sign of stroke.

Once your finger reaches approximately 50 degrees, hold the position momentarily and observe for nystagmus. Repeat to the opposite side. To test for vertical nystagmus, hold your finger midline in front of the face as you slowly move it up and down, pausing momentarily to observe for nystagmus. Nystagmus causes uncontrolled repetitive rapid oscillation of the eye and is best seen on a lateral or vertical gaze. Nystagmus can be horizontal (side to side), vertical (up and down) or rotatory (circular). Assess for it in patients who complain of dizziness or an unsteady gait.

Causes of nystagmus include peripheral vertigo, labyrinthitis (inflammation of the inner year), drugs (seizure medication, benzodiazepines), alcohol and head trauma. When the nystagmus is horizontal or rotary, it is more likely due to a benign condition. However, vertical nystagmus can be an ominous sign of CNS pathology.

Causes of saccades include drug ingestion, drowsiness, cerebellar disorders and degenerative disorders of the central nervous system (e.g., multiple sclerosis).

Facial weakness, CN VII (facial nerve)—To observe the facial muscles for symmetry, ask the patient to smile. Note any facial drooping. Next ask the patient to raise his or her eyebrows, and then tightly shut both eyes. Note any asymmetry. With each of these tests, look for subtle weakness by examining the depth of the wrinkles on each side of the face, including the nasolabial folds (the deep line going from the nostril to the lateral lip). Compare the depth and number of wrinkles on each side of the face. Similar to BOTOX injections, the affected side will have weakened/paralyzed muscles and fewer wrinkles.

Cerebellar Function

Assessing for cerebellar function can help identify less-common posterior circulation strokes.

Finger to nose—This test assesses a patient for loss of coordination and dysmetria, a type of ataxia where the ability to judge distance and speed is impaired. If the patient cannot correctly judge distance and reaches too far or not far enough, the test is positive for dysmetria. Also, if the patient can accurately touch their nose on one side but not the other, it is a positive test for focal cerebellar dysfunction.

To perform the exam, stand in front of the patient. Have the patient touch their nose with their index finger, and then have them touch your finger. Have the patient alternate back and forth between touching their nose and your finger several times. Then move your finger to different locations. You must be far enough away so the patient has to fully extend their arm in order to touch your finger. Have the patient repeat with the opposite hand.

Heel/shin—Have the patient place the heel of one foot on the knee of the opposite leg. Instruct the patient to slide the heel in a straight line down to the foot and back up to the knee several times. Repeat on the other side. If there is a difference in how well a patient can keep their heel on their shin on one side versus the other, it is considered an abnormal test.

Motor Function

This tests the circulation pathways of the anterior brain.

Hemiparesis is defined as unilateral muscular weakness. Patients can still move the affected part of the body but are noticeably weaker. Stroke is the most common cause of hemiparesis.

Hemiplegia is defined as unilateral paralysis. Hemiplegia can occur just in the face, arm or leg, or in a combination all on the same side.

Causes of hemiparesis/hemiplegia: stroke/TIA, head trauma, Todd’s paralysis (temporary weakness after a seizure), migraine headaches, Bell’s palsy (face only).

Upper extremities—To test the upper extremities, have the patient hold their arms out at shoulder level with palms up and eyes closed. Observe both arms for 10 seconds, noting any downward drifting of the arm or inward rotation of the palm (pronator drift).

Asymmetrical upper-extremity weakness is present if the patient cannot raise one arm, if one arm drifts down or if one arm has a pronator drift. Pronator drift is a sign of subtle weakness and is present when one palm begins to turn inward while the other remains up. If both palms rotate inward or both arms drift downward equally, it is simply general weakness and usually not a sign of stroke. Again, asymmetry is what we are looking for.

Lower extremities—To test lower-extremity strength, have the patient lie supine and raise their leg straight up to an angle of about 30–35 degrees, then hold it there while you count to five. If the leg drifts downward, touches the bed or can’t be raised to begin with, it is a positive test. Be aware that pain and decreased mobility from prior hip surgery and chronic bilateral muscle weakness may explain these findings. Unilateral weakness in the absence of prior surgery or other preexisting explanation indicates possible stroke.

Sensory Function

This tests for alteration in the sense of touch.

Numbness is loss of sensation. Paresthesia is an abnormal sensation such as tingling, “pins and needles” or burning of the skin and is most common in the extremities. Alteration of sensation can be elicited by a light touch test. Have the patient close their eyes then lightly touch their right leg, left leg, then both legs at the same time. Repeat the process for the arms and face. Each time the patient is touched, ask them to identify where they are being touched and if it feels the same on both sides. On the simultaneous touch, if a patient only identifies one side even though you are touching both, it’s an indication of neglect, a stroke symptom where the patient ignores some stimuli from the affected side of the body.

Acute numbness or paresthesia causes include stroke (unilateral symptoms), hyperventilation syndrome/panic attacks (generally bilateral paresthesia) and spinal cord injuries.

After the above examinations are performed, the paramedic will have tested the majority of the various brain functions. Any abnormal finding may indicate a stroke or other serious pathology and warrants further investigation in the hospital.

Neurological Emergencies

Instead of an exhaustive review of the neurological history, which would be beyond the scope of this article, we will review some clinical clues present in the history and physical exam that will assist the paramedic in making the correct prehospital diagnosis. We have only included some of the more common types of neurological emergencies, with the pertinent positives listed in each section (see Tables 2–4).

Stroke

There are two types of stroke: ischemic and hemorrhagic. Ischemic stroke is further broken down by large vessel obstruction (LVO) and small vessel obstruction. LVO strokes have recently been proven to have better outcomes when treated with interventional therapy known as stent retrieval.^2,3 It is important for paramedics to know which hospitals in their area can provide this type of advanced care.

Ischemic and transient ischemic (TIA) strokes—One of the most frequently missed yet most important pieces of information with respect to available treatment options is a stroke’s time of onset. Paramedics must rapidly determine when the patient was last known to be normal. This is not necessarily the same time the symptoms were first recognized. With a “wake-up stroke,” the time last known normal may be when the victim went to bed the night before or got up during the night to use the bathroom. If this information is not readily available, the phone number of a witness should be obtained to transmit to the hospital staff. Without having the last-known-normal time, the patient may not be eligible to receive some of the available stroke treatments.

Ischemic stroke/TIA is characterized by a sudden onset of any combination of difficulty with speech, focal motor or sensory function, confusion, visual disturbances, difficulty with coordination or ataxia (unsteady, staggering gait). History may include prior stroke/TIAs, hypertension, a-fib, smoking, excessive alcohol consumption or family history of stroke/TIA.⁴

TIAs present with the same signs and symptoms as an ischemic stroke, but symptoms typically last less than five minutes and no more than 24 hours. TIAs do not cause permanent brain damage, as the blockage is only temporary. However, because stroke symptoms may come and go early in their course, even if a patient improves, the authors feel a “stroke alert” should still be called, since problems may recur. What may initially look like a TIA may worsen and become a large stroke.

Differential diagnosis: Hypoglycemia, migraine headache, seizure (Todd’s paralysis), vertigo, meningitis, head trauma.

Hemorrhagic stroke—This typically presents with a sudden onset of severe (“thunderclap”) headache, often described as the worst of one’s life. It may be associated with an altered mental status, vomiting, focal neurological deficits, seizure and coma. As bleeding continues, the patient may show signs of herniation syndrome: unresponsiveness, blown pupil, vomiting, Cushing’s triad (bradycardia, hypertension and an altered breathing pattern).

Risk factors include hypertension, anticoagulants, brain aneurysms, arteriovenous malformations and prior hemorrhagic strokes.

Differential diagnosis: hypoglycemia, migraine headache, seizure (Todd’s paralysis), vertigo, hypertensive encephalopathy, meningitis, head trauma.

Bell’s Palsy

Bell’s palsy is a common stroke mimic that presents with unilateral facial weakness or paralysis. This occurs when the seventh cranial nerve becomes compressed or inflamed, most likely due to a viral infection. With Bell’s palsy, the patient will have unilateral facial drooping and not be able to raise the eyebrow or close the eyelid as strongly on the affected side. In contrast, only the lower facial muscles are affected in patients suffering from a stroke. Stroke patients will have no difficulty raising both eyebrows and closing both eyes. Associated symptoms of Bell’s palsy may include facial paresthesia, increased sensitivity to sound and an altered taste on the affected side. If the patient presents with any other focal neurological deficits, such as weakness of the extremities or visual disturbances, consider it to be a stroke.

Symptoms typically evolve over 48 hours, and recent viral illness or pain behind the ear on the affected side may precede facial weakness. Differential diagnosis: stroke.

Peripheral Vertigo (Dizziness)

Vertigo is the sudden onset of the sensation of spinning. It is important to differentiate a chief complaint of dizziness between vertigo (a sense of motion or spinning), ataxia (loss of balance) and lightheadedness (feeling faint), as they have different underlying causes. If not differentiated, the symptom of dizziness can lead you down the wrong diagnostic path. For patients with vertigo, movement of the head, especially in the supine position, may provoke symptoms, while remaining still may calm the spinning sensation. Patients with peripheral vertigo will generally have horizontal nystagmus.

History may include a recent viral illness or ringing in the ear. Differential diagnosis: hypoglycemia, migraine headache, stroke.

Meningitis

Consider meningitis in patients with a fever, nuchal rigidity (impaired neck flexion due to muscle spasm) and headache, especially if associated with an altered mental status (lethargy, confusion and coma) or other neurological deficits. Additional symptoms include petechial rash, photophobia, vomiting and seizures.

History: Flu-like symptoms (fever, head and body aches). Differential diagnosis: stroke, migraine headache.

The Pit Crew Approach

Just like the pit crew for a race car driver acts rapidly as a team to efficiently get the car back to racing, the pit crew method in EMS allows a crew to rapidly assess and begin the stabilization, treatment and transport of patients with life-threatening illness or injury. For example, in the case of cardiac arrest, depending upon the number of crew available, one crew member should be assigned to begin chest compressions within 30 seconds of patient contact, one wields the monitor/defibrillator, one manages the airway, and another administers the medications.

In the case of a chief complaint possibly consistent with a stroke, one team member should have been assigned to perform a rapid stroke assessment within the first few minutes of patient contact to determine if a stroke alert is present. Other team members can gather critical medical history, especially the time the patient was last known to be normal, plus medications, allergies, etc. To minimize on-scene time for critically ill stroke patients, calling a stroke alert on eligible patients within the first few minutes of contact should be the goal of the pit crew method.

Conclusion

Now that we have reviewed the neurological history and physical exam, let’s apply it to our patient complaining of dizziness and weakness.

Using the pit crew method, your team has a member preassigned to immediately perform a Cincinnati Prehospital Stroke Scale on the patient, and it is found to be completely normal. After reading this article, you know many strokes are not detected by the standard prehospital stroke screens, so your team proceeds to do a more detailed neurological history and physical exam.

You learn that what the patient calls “dizziness” to her means loss of balance. The onset was sudden, about an hour ago, and has not improved. It is worse if she tries to walk. There are no alleviating factors. She has a past history of TIA and a-fib. She has no headache.

You and your team perform a full neurological exam and notice the patient has equal strength, sensation and cranial nerve function bilaterally. However, when you perform the finger-to-nose and heel-to-shin tests, you note the patient seems to have loss of coordination on the right side of the body. Based upon this information, you call a stroke alert and transport the patient to the nearest comprehensive stroke center. There doctors inform you the patient is having a posterior circulation stroke involving the balance center of the brain and will be taken emergently to the brain cath lab for treatment. You and your team have just saved another life.

References

1. Studnek JR, Asimos A, Dodds J, Swanson D. Assessing the validity of the Cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care, 2013 Jul–Sep; 17(3): 348–53.

2. Berkhemer OA, Fransen PS, Beumer D, et al.; MR CLEAN investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med, 2015 Jan 1; 372(1): 11–20.

3. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med, 2015 Jun 11; 372(24): 2,285–95.

4. National Stroke Association, www.stroke.org.

Kenneth A. Scheppke, MD, is board-certified in EMS and emergency medicine. He has been practicing emergency medicine for over 20 years and is the EMS medical director for six fire-rescue agencies in Palm Beach County, FL, including Palm Beach Gardens, Palm Beach County, West Palm Beach, Boynton Beach, the Town of Palm Beach and Greenacres. For more than 15 years he has trained paramedics and EMTs as medical director for the Palm Beach State College EMS Academy. He also serves as the assistant medical director of the JFK Medical Center emergency department in Atlantis, FL.

Keith Bryer, BBA, EMT-P, has been employed with Palm Beach Gardens Fire Rescue for more than 25 years. He currently serves as the department’s deputy chief of operations.