Subjective

CC: “I’ve had a really bad headache for the last 2 days. I was in the emergency room closer to
my house and told it was a migraine. It’s getting worse and now I’m having trouble walking.”

HPI: B.B is a 31 yom who was in his usual state of health until 2 days ago when he presented to
the ED with a progressively worsening right-sided headache. Pt reports headache as a non-
radiating, sharp constant pain rated 6/10 intensity. Pain is worsened with standing or walking and
not alleviated with Excedrin or Tylenol. At time of onset, he was sitting at his work desk when
he felt a sudden sharp pain in the right side of his head that has not gone away since. Per pt, the
previous ED stated he has a migraine headache. Pt also reports feeling dizzy and nauseous, but
has not been able to vomit. Pt describes difficulty walking with his left leg feeling “heavy” and
inability to feel where he’s stepping. He also states that his right face and left hand feels numb,
with new onset of hiccups since last night, and that he has intermittent double vision since
yesterday. Pt denies past episodes of headaches, recent head or neck trauma, photophobia, or
changes in mental status. He has had no prior diagnosis of seizures or neurologic conditions.

ROS: Pt denies fever, viral or bacterial infections, chest pain, palpitations, blurred vision,
blue/cold fingers, urinary changes, bowel changes

PMH: uncontrolled HTN

Medications: Acetaminophen unknown dosage
Allergies: NKDA
SHx:
Employed full time as a hospital-based social worker
Lives with wife and 4-year-old son
Tobacco: 7.5 pack-year smoking history; recently quit 2 weeks ago
Alcohol: 1 beer or glass of wine daily
Illicit-drug use: none
Denies sexual activity, dx of STIs
FamHx:
Mother died of CVA at 50; DM and HTN
Father died at 38 of MI
Grandparents status unknown

Objective:
v/s:
T: 36.9ºC (oral)
P: 76 bpm - regular
BP: 164/104mmHg supine/sitting and 160/104mmHg upon standing (uncontrolled)
RR: 16 bpm
SpO2: 97%

GA: Well groomed young adult, A & O x 4, NAD

HEENT: anicteric, no evidence of head trauma, skin lesions, lymphadenopathy, papilledema,
PERLA,
CVS: S1 and S2 heart sounds normal, no murmurs or gallop, RRR,
Neurlogical: CN I-XII intact, positive Romberg and sitting ataxia with falls to the right, weak on
left hand grip and left leg raise compared to right, normal head tilt test, skew deviation
(hypertrophic deviation on the left), torsion nystagmus, normal red reflex bilaterally, optic disks
sharps, no signs of papilledema

Assessment
Wallenberg syndrome/Lateral medullary syndrome
- Progressively worsening, right-sided headache, vertigo and ataxia x 2 days
- diplopia
- Bidirectional horizontal nystagmus
- Sensory loss right side face, left side hand and leg
- Hiccups
- Brain MRI finding: 5x5 nonenhancing lesion in the right lateral medulla
Stroke, ischemic
- Progressively worsening, right-sided headache
- diplopia
- sensory loss right side face, left side hand and leg
- vertigo, ataxia
- risk factors: family hx of CVA, elevated total cholesterol (275mg/dL) and
triglycerides (315mg/dL)
Cerebellar stroke
- Headache and diplopia
- ataxia
- Vertigo
Plan
1. Admit to acute-stroke service for neuro monitoring
a. Obtain neurosurgery/endovascular evaluation
b. Vasculitis and hypercoagulable-state work-up
2. Stroke prevention with
a. ASA 81mg
b. Atorvastatin 80mg qHs for lipid lowering and cardioprotective effect
c. Lisinopril 10mg for HTN
3. Acute rehabilitation with PT/OT, continued encouragement of smoking cessation

Evidence Based Discussion

In young adult patients that present with rapid onset of vertigo, nausea/vomiting, and gait
unsteadiness, does a bedside Head-Impulse-Nystagmus-Test-of-Skew (HINTS) exam allow
practitioners to rule in or out a must not missed diagnosis earlier than ordering an MRI diffusion-
weighted imaging? In the article “HINTS to Diagnose Stroke in the Acute Vestibular
Syndrome”, authors aim to provide insight into a “3-step bedside oculomotor examination” to
efficiently assess patients that present with neurological symptoms that may be due to a stroke or
other etiologies such as vestibular neuritis or labyrinthitis, classified as acute peripheral
vestibulopathy (APV). I chose this article to explore other tools in assessing patients with
neurological signs and symptoms not dependent on age to aid in differential diagnosis.
Patients such as B.B., who is a 31-year-old with neurological symptoms (unilateral headache,
vertigo and ataxia) would more commonly be attributed to a migraine headache or variation
thereof as evident from his ED visit 2 days ago. The researchers conducted a prospective, cross-
sectional study with patients that had characteristics of an acute vestibular syndrome (AVS),
such as vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait and had ≥1
stroke risk factor. The first step of the “3-step bedside” exam was to examine the vestibulo-
ocular reflex function. They chose the oculomotor examination due to the variability of AVS
patients having less than half of the common symptoms, whereas the vestibulo-ocular reflex
function was a more consistent bedside predictor. If the patient demonstrated a normal reflex the
physician would be able to rule out a viral cause affecting the vestibulochochlear nerve. In
patient B.B., he demonstrated a normal head tilt test, which in this case is considered ‘abnormal’
in the sense that a central pathology may be the cause. The second step is to check for
nystagmus, which changes direction on eccentric gaze to the right or to the left. In most strokes
that present with an AVS component, the patient may have a horizontal nystagmus which
mimics APV, but if a patient presents with a beating nystagmus when gazing to the left and then
gazing to the right, it points more towards a central pathology. The last step to predicting a
central pathology is skew deviation in which vertical ocular misalignment results from a neural
firing imbalance which is seen when you alternate between uncovering one eye and seeing the
patients eye re-fixate.

The 3-step approach to looking for signs in patients with neurologic symptoms independent of
age and advancements of the hospital may help reduce the misdiagnosis in patients that present
acutely. Researchers have shown that HINTS was 100% sensitive and 96% specific for stroke as
a result of the study. Moreover, the HINTS takes approximately 1 minute at the bedside versus a
5-10 minute MRI scan time and is cost-effective for the patient and physician. The use of HINTS
at the bedside may have helped BB’s situation of misdiagnosis at his first ED visit.

Citation: Kattah, J., Talkad, A., Wang, D., Hsieh, Y. and Newman-Toker, D., 2009. HINTS to
Diagnose Stroke in the Acute Vestibular Syndrome. [online] AHA Journals. Available at:
<https://www.ahajournals.org/doi/10.1161/STROKEAHA.109.551234> [Accessed 21 April
2021].

Reflective Writing
My first encounter with a stroke patient was when I was 14 years old. I traveled with my mother,
a registered nurse, to the Philippines to take care of my grandpa. He was 70 years old and had
suffered a cerebrovascular accident which left him confused, forgetful, and weak on one side.
With the limited hospital resources, my mother kept him comfortable, had music playing at all
times (he was a band director), encouraged physical activity with short walks down the hall, and
constantly asked him questions to jog his memory. Since then, the situation has been a reference
point in my life when it comes to thinking of patients that are elderly and present with
neurological symptoms.

In B.B.’s case, I had an inclination of making an anchoring error due to his age and lowered the
differential diagnosis of a central pathology. I had difficulty reevaluating my differentials after
taking a history of present illness and ended up performing more physical exam tests than
necessary. When I read about the HINTS examination, I was excited to learn more about a highly
sensitive, quick bedside exam to add to my arsenal of diagnostic tools. I thoroughly enjoyed
reading about the HINTS examination because it was a systematic way to rule in or out a
peripheral or central cause of neurologic signs and symptoms. I think with the technological
advancements in everyday life and in medicine, it may be easier to rely on imaging and labs to
narrow down a diagnosis, but it is not always the efficient choice. In many situations where the
‘classic patient presentation’ is atypical or there are not enough resources, it frequently comes
back to the HPI and the basic foundations of a performing a physical examination. This is what
separates physicians from “Dr. Google”, the ability to think through a problem organically
because the patient is a human being and not a list of symptoms and checklists.

In a way, physicians trained in third-world countries like the Philippines, have the ‘unfair’
advantage of not being bogged down by a variety of tests they can order. As a result, the
physician has the opportunity to focus solely on what is in front of them, the patient. I believe
that the phrase, “do no harm” should not only be applied to the patient’s well-being, but also to
their support system which includes finances, and ordering a battery of tests contributes to
financial burden. If I find myself in a similar situation as a physician in the Philippines, I would
think twice before ordering an MRI as soon as a patient with vertigo is brought in.

When I have taught pre-medical students about signs and symptoms, I used to joke that “the eyes
are the window to your liver” but after learning about the HINTS examination I can add on “the
eyes are the window to your liver… and neurological functioning.” Because when all else fails,
such as technology or our own biases hold us back, we are left with our innate senses and
knowledge of how to piece things together.