ER Doctors Fail to Diagnose Stroke

This is an extremely common patient presentation that I see on a very frequent basis, at least once per shift. The standard workup for this presentation varies widely. In some cases, a thorough history and physical will provide enough diagnostic information; in others, laboratory and radiologic studies are indicated. In this case both CT and MRI were performed, suggesting that the ordering clinician had a high index of suspicion for significant pathology. Neck and back pain, diaphoresis, and nausea are relatively non-specific complaints that have an extremely large differential diagnosis. Further history and physical exam information would help begin the narrowing process but, to begin with, a differential might include: meningitis, vertebral or carotid artery dissection, intracranial bleed, aortic dissection/aneurysm, myocardial infarction, esophageal/pharyngeal rupture, pulmonary embolus, soft tissue neck infection including cellulitis, abscess and necrotizing infection, fracture or other traumatic injury, spinal stenosis, syrinx, neuropathy, spinal infarct, and pneumonia. Follow up to monitor such a patient would really depend on their condition at discharge. If pain had not been controlled adequately in the emergency department, admission to an inpatient bed for both pain control and 24 hour observation may have been warranted. If pain could be controlled adequately, follow up within 24 hours for recheck would usually be the standard of care given the clear extensive nature of the pain and the clear clinical concern of the treating physicians who ordered extensive diagnostic testing.