Category
|
Concerning Features *Necessitates immediate transfer to ED
|
Example Diagnoses
|
Testing to Consider
|
Neurologic
|
HISTORY:
- Seizures*
- Headache +/- associated photophobia, phonophobia, diplopia, blurry vision, visual field defects, or aura
- Olfactory or gustatory hallucinations
- Stereotyped hallucinations (simple, visual hallucinations that recur as the same perception)
- Insight to hallucinations
- Known head trauma
EXAM:
- Altered level of consciousness*
- Aphasia, dysarthria, or incoherent speech*
- Cranial nerve deficit
- Dystonia, clonus, rigidity, weakness, or choreiform movements
- Hyper/hyporeflexia
Ataxia, nystagmus, or dysmetria
- Kayser-Fleisher rings
|
- Head trauma
- Epilepsy
- Delirium
- Stroke
- Migraine
- Brain mass (tumor, arteriovenous malformation, cyst, abscess, tuberous (sclerosis)
- Multiple sclerosis
- adrenoleukodystrophy
- Wilson's disease
- Narcolepsy
- Kleine-Levin syndrome
- CNS vasculitis abscess, tuberous (sclerosis)
- Juvenile Huntington's disease
|
|
Toxicologic
|
HISTORY:
- Known substance abuse*
- Association with medication (e.g., dystonia with anti-psychotics)
EXAM:
- Altered level of consciousness
- Pupillary abnormalities
|
- Medication side effects or interactions
- Accidental toxic ingestion
- Substance use-related disorders (e.g., intoxication or withdrawal)
- Heavy metal poisoning
|
- Urine drug screen
- Heavy metal panel
|
Infectious
|
EXAM:
- Toxic appearance
- Fever +/- abnormal vital signs
- Lethargy
- Meningismus
|
- HIV
- Neurosyphilis
- Viral or bacterial encephalitis
- Meningitis
- Neurocysticercosis
|
- Urinalysis with reflex urine culture
- CBC with differential
- CRP
- CSF studies
- HIV antigen/antibody
- RPR
|
Rheumatic/Autoimmune
|
HISTORY:
EXAM:
- Oral ulcers
- Hyperpigmentation
- Rash (malar rash, vasculitic rash, erythema nodosum)
- Nail changes
- Hair loss
- Arthritis
|
- Systemic lupus erythematosus
- Sarcoidosis
- Paraneoplastic syndrome
- Autoimmune encephalitis
- Post-infectious encephalitis or ADEM
|
- ANA
- Urinalysis
- SLE-specific labs
- Neuroimaging
|
Endocrine
|
HISTORY:
- Unexplained weight changes
- Fatigue
EXAM:
- Abnormal vital signs
- Abnormal thyroid exam
- Skin or hair changes
- Abnormal vital signs
|
- Hyper/hypothyroidism (Hashimoto encephalitis, thyroiditis)
- Hyperparathyroidism
- Hypoglycemia
- Addison’s disease
- Pheochromocytoma
- Cushing disease
- Catamenial disorders
|
- TSH
- Free T4
- Calcium, PTH, alkaline phosphatase
|
Metabolic
|
HISTORY:
- Early age of onset
- Developmental delay or regression
- Fatigue
- Vomiting
EXAM:
- Lethargy
- Abnormal growth curve
|
- Porphyria
- Urea cycle defects, fatty acid oxidation defects
- Niemann-Pick disease
- Nutritional deficiencies (Mg, vitamin A/B1/B3/B12)
|
- Complete metabolic panel
- Urinalysis
- Plasma amino acids
- Urine organic acids
- Acylcarnitine profile
- Urine protein: creatinine ratio
- Ammonia
|
