34 year old Caucasian patient presents to the emergency room to on February 13, 2012 at approximately 11:00 a additional info.m., complaining of nausea, vomiting and pneumonia-type symptoms. Patient is 5’7” tall and weighs approximately 189 lbs. He presented with a low grade temperature of 97.1 and gave a history of having high cholesterol. A neurological examination revealed the patient to be dizzy and light headed. Under the Hendrick II Fall Risk Assessment, it was noted that he had both dizziness and vertigo. Although the emergency room records do not reflect this, the patient’s wife who accompanied him, indicated that he continued to complain of vision changes and severe headaches on the left posterior side of the head and requested Tylenol multiple times due to the severity of his symptoms. After performing an EKG (negative) and a chest x-ray (negative), the patient was discharged home with a diagnosis of a stomach flu.
Within hours of arriving at home (approximately 2:00 p.m. on February 13, 2012), the patient passed out in the kitchen. His wife, a physical therapist, assessed his breathing and determined that he was in fact breathing. The patient was unconscious for approximately 2 minutes and when he awoke, he was extremely confused. His wife called 911 and he was brought back to the same emergency department. A CT scan and MRI of the brain showed an acute CVA of the left temporal-occipital area. The findings were consistent with an acute infarction involving the left posterior cerebral artery territory. Currently, the patient suffers from seizure disorder as well as a loss of visual fields in both eyes.
ISSUE: We are interested in learning from your experts if the emergency room staff should have taken further steps in assessing the patient when he first presented and would the outcome would have made a difference in his outcome.
MEDICAL EXPERT RESPONSES:
When this patient first presented to the ER at 11AM, he had already sustained the stroke which was discovered later that same day. With the complaints of left posterior headache with dizziness, the standard of care was to at least have undergone a CT scan of the head. However, the tough question is whether earlier diagnosis would have changed the outcome. If he presented within 4.5 hours of onset of symptoms, he would have been a candidate for tPA which could have potentially changed the ultimate severity and size of the stroke. If he woke up that morning with these symptoms, he would not have been a tPA candidate.
Bottom line: The time of symptom onset is the key. And even if he was in the window of time to receive tPA, that is not a >50% guarantee that anything would have changed the ultimate outcome. Dr GB – Neurologist
I recommend formal review for this case because it appears that the history of the headache with vertigo and vision changes should have been obtained by the emergency department staff. The most likely cause in a 34-year-old is benign positional vertigo, and this would’ve been treated with vertigo medications, which would not have been affective since the patient was having a stroke. When the medicines did not work a head CT should have been performed. And even if this was negative at this point in the evolution of the stroke the patient most likely would’ve been admitted for persistent vertigo and then subsequently the stroke would’ve been diagnosed. Dr SJ – ER
At age 34, it is highly unlikely that he should have had a stroke. also, the duration of symptoms at first presentation is not reported here, but if anything longer than a couple hours, he would have been outside the window for any potential intervention by the time he had had a CT scan. I would not be able to support this as a case. Dr KJ – ER