New grad medical question

[cj9727]

Hi, I'm a new grad PA and new to this forum.

I'm not clear when I should say if pt has " focal neuro deficit"

If patient presents with the neurologic symptoms such as R face numbness with blurry vision after head concussion but neuro exam is normal, can I still say patient has focal neuro deficit ?

[EMEDPA]

"subjective neurologic changes."

make sure to document specifically all the normal features of the exam to substantiate this.

(pt states face feels weak but has nl motor exam, no visible droop, can smile, wrinkle forehead, etc).

[cj9727]

Thanks!!!!!!

[Reality Check 2]

Document Snellen vision as well. Then you can say "reports blurry vision, vision OU 20/30"

Report what they say, document what you see

[winterallsummer]

The answer IMO is no even though those are subjective, they are Neuro deficits. The best thing to do in that case is document those abnormalities in the history and then document all normal Neuro exam findings (eg strength 5/5, PERRL, etc) and just not mention "no focal deficits." The other thing would be in be HPI to document those subjective findings and then write "however with otherwise normal neurological exam."

 

Now as far as using scoring systems such as CT head rules, my understanding is those subjective findings do count as focal deficits such as blurry vision. Patients who are psychosomatic obviously are not always best served by these rules but with trauma as a new PA it's probably best to err on the side of caution anyway (in case that's why you are asking).

[Reality Check 2]

I just reread this and then read winterallsummer 

 

PLEASE never document WNL - it means We Never Looked

 

PLEASE always document that the PERRLA and the cranial nerves are intact and there is no nystagmus and there is no pronator drift and etc etc etc etc

 

EMRs sometimes make it tempting to check the normal box if there is one. The old saying is that G-d is in the Details - please make detailed notes and make sure anyone coming behind you to examine the patient sees what you saw in your notes.

 

Paint a picture of the patient that gives the next provider or specialist a clear view of this patient as a person and not some EMR click festival of meaningful use bullets that are indeed useless.

[jb5158]

I agree with all of the above. I work in neurology and "focal neurologic deficits" are what is observed on exam, i.e. "Pt is a 40 y/o M c/o blurred vision and headache. No focal neurologic deficits on exam, so will hold off on neuroimaging, etc."