Author: Teresa S. Wu, MD Reviewer: Thomas Payton, MD
Case Title: “I think I’m having a stroke!”
Target Audience: medical students, physicians’ assistants, nurse practitioners, residents
Primary Learning Objectives: key learning objectives of the scenario
1. The participant will obtain a detailed history and perform a comprehensive neurological exam.
2. The participant will formulate a broad & comprehensive differential diagnosis for patients presenting with vertigo.
3. The participant will avoid anchoring into a diagnosis and will carefully consider the data presented in the case.
4. The participant will explain the pathophysiology of Meniere’s Disease and offer options for symptomatic control and surgical treatment.
Secondary Learning Objectives:
1. The participant will actively manage and reassess the patient’s symptoms (IV antiemetics, benzodiazepines, IVF’s, etc.)
2. The participant will order the correct tests to rule-out an acute cerebral event
3. The participant will order the correct blood work to rule-out co-existing metabolic, hormonal, or endocrinological disturbances.
4. The participant will demonstrate compassion and empathy during the evaluation and management of the patient
Critical actions checklist:
1. Places patient on a cardiac monitor with pulse oximetry
2. Obtains a bedside ECG
3. Places the patient on supplemental oxygen
4. Checks a bedside point-of-care glucose
5. Performs a full neurological exam
6. Performs a hearing test
7. Orders a CT scan to rule out acute intracranial pathology
8. Places a peripheral IV
9. Draws labs to evaluate for metabolic disturbances, infections, and endocrine or hormonal abnormalities contributing to the symptomatology.
10. Elicits a history of vertigo, tinnitus, and hearing loss from the patient and makes the diagnosis of Meniere’s Syndrome.
11. Obtains a neurological consult to aid in the patient’s disposition
Environment
1. Room Set Up – Emergency Department Resuscitation Bay
a. Mannequin: SimMan 3G with a female wig
b. Equipment:
1. Cardiac Monitor
2. Blood pressure cuff (manual and automatic)
3. Peripheral IVs (18 gauge, 16 gauge)
4. Gauze
5. Tape
6. Tourniquet
7. Tegaderm
8. IV caps or heplocks
9. Oxygen Source/Tree
10. Non-rebreather
11. IV fluids (NS and LR)
12. Blood collection tubes (rainbow)
13. Urine specimen
14. Lab reports (CBC, CMP, coagulation panel, UA, cardiac enzymes)
15. Meclizine
16. Ativan
17. Antiemetics (zofran, phenergan, compazine, etc.)
18. Aspirin
19. Normal EKG
20. Normal head CT
21. Phone call to consults
Actors (optional)
1. Nurse
2. Paramedics to give report about the patient
3. Patient’s husband
4. Neurologist
5. Radiology technician
For Examiner Only
Author: Teresa S. Wu, MD
Case Title: “I think I’m having a stroke!”
CASE SUMMARY
CORE CONTENT AREA
Otolaryngology
SYNOPSIS OF HISTORY/ Scenario Background
A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. She was outside working on the garden when she started to feel dizzy. She went inside to “cool off” and started developing a “headache”. Her husband called 911 because he thought she was having a stroke.
When asked, the patient will note that her headache feels like “fullness” that came on gradually. Now she feels like the room is spinning. She’s had no visual changes, but she feels like there is a “buzzing in her ear”. She denies any chest pain, shortness of breath, paresthesias, weakness, nausea, or vomiting. This is the first time she has experienced these symptoms. She cannot recall any inciting event.
Past Medical History: HTN
Medications: Lisinopril
Allergies: PCN
Family History: HTN, CAD
Social History: Married. Retired. Denies EtOH, tobacco, or illicit drugs.
SYNOPSIS OF PHYSICAL
Patient is sitting upright in the gurney, diaphoretic, complaining of dizziness.
Her neurological exam is significant for decreased hearing on the left, nystagmus, and a positive Romberg.
HR 90 BP 167/52 RR 18 O2 Sat 99% Temp 37.6
For Examiner Only
CRITICAL ACTIONS
Scenario branch points/ PLAY OF CASE GUIDELINES
1. Critical Action
The participant should order a head CT or MRI to rule out an acute cerebral event.
Cueing Guideline: The patient and her husband should continue to ask the participant if she is having a stroke.
2. Critical Action
The participant should perform a thorough neurological exam and note that the patient’s exam is only notable for fatigable nystagmus and a positive Romberg test.
Cueing Guideline: The patient continues to complain that she feels “really, really dizzy”.
3. Critical Action
The participant should inquire more about the “roaring sound” and ask about associated tinnitus.
Cueing Guideline: The patient starts to complain that there is a “roaring sound” in her ears and that the sound is making her headache worse.
4. Critical Action
The participant should assess the patient’s hearing either through a gross assessment with finger rubs or via a tuning fork (Rinne and Weber’s tests).
The patient continues to ask the participant to repeat each question asked because she is “having a hard time hearing” him/her.
5. Critical Action
The participant should send the following blood tests to rule-out other certain metabolic disturbances, infections, and endocrine or hormonal abnormalities contributing to the symptomatology:
· TSH, Free T4 and T3
· CBC
· BMP
· ESR
· CRP
· UA
· FTA-ABS
Cueing Guideline: The nurse asks the participant what lab tests he/she would like to send.
Maximum Points for Critical Actions: 10 points
SCORING GUIDELINES
(Critical Action No.)
1. 2 points awarded if the CT or MRI is obtained.
2. 2 points awarded if a full neurological exam is performed. 1 point awarded if a partial neurological exam is performed.
3. 2 points awarded if the participant elicits more history and details concerning the “roaring sound” the patient is endorsing. 1 point awarded if the participant simply acknowledges the complaint.
4. 2 points awarded if the participant assesses the patient’s hearing by performing both Rinne and Weber’s tests. 1 point awarded if the participant performs only one of the above mentioned tests or simply evaluates for gross hearing loss through finger rub.
5. 2 points awarded if the participant orders all of the blood tests listed above. 1 point awarded if partial blood work is ordered.
For Examiner Only
HISTORY
Onset of Symptoms: The symptoms began gradually about an hour prior to arrival to the ED.
Background Info: A 60 y.o. female is brought in by EMS with a chief complaint of dizziness.
Chief Complaint: The patient was outside working on the garden when she started to feel dizzy. She went inside to “cool off” and started developing a “headache”. Her husband called 911 because he thought she was having a stroke. She has never had symptoms like this before and she feels like her dizziness is getting worse. She feels diaphoretic and nauseated.
Past Medical Hx: HTN
Past Surgical Hx: None.
Habits: Denies smoking, ETOH, or illicit drugs.
Family Medical Hx: HTN, CAD
Social Hx: Marital Status: married
Children: one, healthy
Education: BS
Employment: retired
ROS:
Positive for dizziness/vertigo, “roaring in her ears”, an occipital headache, decreased hearing, nausea, diaphoresis, and “feeling faint”
Negative for any chest pain, palpitations, shortness of breath, visual changes, weakness, paresthesias, abdominal pain, extremity swelling, or pain
For Examiner Only
PHYSICAL EXAM
Patient Name: Margaret Davenport Age & Sex: 60 y.o. female
General Appearance: Well-developed, well-nourished female in moderate distress. She is sitting upright in the gurney, diaphoretic, and moaning.
Vital Signs: HR 90 BP 167/52 RR 18 O2 Sat 99% Temp 37.6
Head: Normocephalic. Atraumatic.
Eyes: PERRLA bilaterally. Horizontal, fatigable nystagmus to the left. EOMI. No scleral icterus.
Ears: Normal TM’s bilaterally. Decreased hearing on the left. Weber test lateralizes to the right. Rinne test indicates that air conduction is better than bone conduction on the right.
Mouth: Clear. Moist. No asymmetry.
Neck: Supple. No masses. No JVD. No thyroid enlargement. No midline TTP.
Skin: Warm and dry. No rashes, cyanosis, or edema. 2+ capillary refill bilaterally.
Chest: No crepitus. No signs of trauma.
Lungs: CTA bilaterally. No rales, rhonchi or wheezes. Good air movement bilaterally.
Heart: RRR. No murmurs, rubs, or gallops. Normal S1 and S2.
Back: No spinal TTP. No CVAT.
Abdomen: Soft, NT/ND. +BS. No HSM.
Extremities: No cyanosis, clubbing, or edema. Normal range of motion bilaterally.
Rectal: Normal tone. Guaiac negative.
Pelvic: No discharge or bleeding. No CMT. No adnexal fullness or TTP. Normal uterine size.
Neurological: A&O x 4. CN II is diminished grossly bilaterally. CNIII-XII grossly intact. 4+ strength bilaterally throughout. No pronator drift. +Romberg. 2+ DTR’s bilaterally throughout. Normal heel to shin. Normal finger-to-nose. No dysdiadochokinesia.
Mental Status: Alert, coherent, with good insight.
For Examiner Only
STIMULUS INVENTORY
#1 Emergency Admitting Form
#2 BMP
#3 LFTs
#4 Magnesium
#5 Urine Drug Screen
#6 CBC
#7 Coagulation panel
#8 TSH
#9 EKG
#10 Head CT
For Examiner Only
LAB DATA & IMAGING RESULTS
Stimulus #2
Basic Metabolic Profile (BMP)
GLUCOSE 121 Latest Range: 60-99 MG/DL
SODIUM 140 Latest Range: 133-145 MEQ/L
POTASSIUM 4.9 Latest Range: 3.5-5.3 MEQ/L
CHLORIDE 106 Latest Range: 98-108 MEQ/L
CO2 23 Latest Range: 23-32 MEQ/L
BUN 7 Latest Range: 7-23 MG/DL
CREATININE 0.8 Latest Range: 0.6-1.3 MG/DL
CALCIUM 9.3 Latest Range: 8.5-10.3 MG/DL
Stimulus #3
Liver Function Tests (LFTs)
TOTAL PROTEIN 7.3 Latest Range: 6.1-7.9 GM/DL
ALBUMIN 4.0 Latest Range: 3.5-5.5 GM/DL
BILIRUBIN TOTAL 0.8 Latest Range: 0.1-1.4 MG/DL
BILIRUBIN DIRECT 0.2 Latest Range: 0.0-0.4 MG/DL
PHOSPHORUS 2.7 Latest Range: 2.4-4.7 MG/DL
ALK PHOSPHATASE 78 Latest Range: 0-135 IU/L
SGOT 41 Latest Range: 0-41 IU/L
SGPT 40 Latest Range: 0-63 IU/L
Stimulus #4
MAGNESIUM 2.0 Latest Range: 1.7-2.8 MG/DL
Stimulus #5
Urine Drug Screen
MARIJUANA SCREEN NEGATIVE No range found
COCAINE MET SCREEN NEGATIVE No range found
AMPHETAMINE SCREEN NEGATIVE No range found
METHAMPHETAMINE SCRN, UR NEGATIVE No range found
BARBITURATE SCREEN NEGATIVE No range found
OPIATES SCREEN NEGATIVE No range found
PHENCYCLIDINE SCREEN NEGATIVE No range found
METHADONE SCREEN NEGATIVE No range found
BENZODIAZEP SCRN NEGATIVE No range found
TRICYCL ANTIDEPRESS SCRN, UR NEGATIVE No range found
Stimulus #6
Complete Blood Count (CBC)
WBC 10.0 Latest Range: 4.0-10.0 THOU/CU MM
RBC 4.9 Latest Range: 4.30-5.90 M/UL
HEMOGLOBIN 13.0 Latest Range: 13.0-17.0 GM/DL
HCT 39.0 Latest Range: 39.0-51.0 %
MCV 92.7 Latest Range: 81.0-99.0 CU MICRONS
MCH 31.0 Latest Range: 27.0-33.0 UUG
MCHC 33.5 Latest Range: 32.5-36.5 %
RDW 11.7 Latest Range: 11.6-14.8 %
PLATELET COUNT 380 Latest Range: 150-400 THOU/CU MM
Differential
NEUT% 74 Latest Range: 40.0-74.0 %
LYMPH% 26 Latest Range: 12.0-40.0 %
MONO% 9.7 Latest Range: 4.0-12.0 %
EOSIN% 0.0 Latest Range: 0.0-8.0 %
BASO% 0.3 Latest Range: 0.0-2.0 %
Stimulus #7
Coags
PT 15 Latest Range: 12–15 seconds
INR 1.0 Latest Range: 0.8-1.2
Stimulus #8
TSH 2.0 Latest Range: 0.4-5 mIU/mL
Free T4 1.0 Latest Range: 0.7-1.5 ng/dL
Stimulus #9
EKG: normal
Stimulus #10
CT head: normal
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name: Margaret Davenport
Age: 60 year old
Sex: Female
Method of Transportation: EMS
Person giving information: Patient and her husband
Presenting complaint: Dizziness
Background: A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. Her husband is present in the room.
Triage or Initial Vital Signs
HR 90 BP 167/52 RR 18 O2 Sat 99% Temp 37.6°C
Learner Stimulus #2
Basic Metabolic Profile (BMP)
GLUCOSE 121 Latest Range: 60-99 MG/DL
SODIUM 140 Latest Range: 133-145 MEQ/L
POTASSIUM 4.9 Latest Range: 3.5-5.3 MEQ/L
CHLORIDE 106 Latest Range: 98-108 MEQ/L
CO2 23 Latest Range: 23-32 MEQ/L
BUN 7 Latest Range: 7-23 MG/DL
CREATININE 0.8 Latest Range: 0.6-1.3 MG/DL
CALCIUM 9.3 Latest Range: 8.5-10.3 MG/DL
Learner Stimulus #3
Liver Function Tests (LFTs)
TOTAL PROTEIN 7.3 Latest Range: 6.1-7.9 GM/DL
ALBUMIN 4.0 Latest Range: 3.5-5.5 GM/DL
BILIRUBIN TOTAL 0.8 Latest Range: 0.1-1.4 MG/DL
BILIRUBIN DIRECT 0.2 Latest Range: 0.0-0.4 MG/DL
PHOSPHORUS 2.7 Latest Range: 2.4-4.7 MG/DL
ALK PHOSPHATASE 78 Latest Range: 0-135 IU/L
SGOT 41 Latest Range: 0-41 IU/L
SGPT 40 Latest Range: 0-63 IU/L
Learner Stimulus #4
MAGNESIUM 2.0 Latest Range: 1.7-2.8 MG/DL
Learner Stimulus #5
Urine Drug Screen
MARIJUANA SCREEN NEGATIVE No range found
COCAINE MET SCREEN NEGATIVE No range found
AMPHETAMINE SCREEN NEGATIVE No range found
METHAMPHETAMINE SCRN, UR NEGATIVE No range found
BARBITURATE SCREEN NEGATIVE No range found
OPIATES SCREEN NEGATIVE No range found
PHENCYCLIDINE SCREEN NEGATIVE No range found
METHADONE SCREEN NEGATIVE No range found
BENZODIAZEP SCRN NEGATIVE No range found
TRICYCL ANTIDEPRESS SCRN, UR NEGATIVE No range found
Learner Stimulus #6
Complete Blood Count (CBC)
WBC 10.0 Latest Range: 4.0-10.0 THOU/CU MM
RBC 4.9 Latest Range: 4.30-5.90 M/UL
HEMOGLOBIN 13.0 Latest Range: 13.0-17.0 GM/DL
HCT 39.0 Latest Range: 39.0-51.0 %
MCV 92.7 Latest Range: 81.0-99.0 CU MICRONS
MCH 31.0 Latest Range: 27.0-33.0 UUG
MCHC 33.5 Latest Range: 32.5-36.5 %
RDW 11.7 Latest Range: 11.6-14.8 %
PLATELET COUNT 380 Latest Range: 150-400 THOU/CU MM
Differential
NEUT% 74 Latest Range: 40.0-74.0 %
LYMPH% 26 Latest Range: 12.0-40.0 %
MONO% 9.7 Latest Range: 4.0-12.0 %
EOSIN% 0.0 Latest Range: 0.0-8.0 %
BASO% 0.3 Latest Range: 0.0-2.0 %
Learner Stimulus #7
Coags
PT 15 Latest Range: 12–15 seconds
INR 1.0 Latest Range: 0.8-1.2
Learner Stimulus #8
TSH 2.0 Latest Range: 0.4-5 mIU/mL
Free T4 1.0 Latest Range: 0.7-1.5 ng/dL
Learner Stimulus #9
EKG: Normal EKG demonstrating sinus tachycardia at 90-100 bpm
Learner Stimulus #10
CT Head: normal
For Examiner
Date: Examiner: Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one of the following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions / NI / ME / AE / NA / CategoryPlaces patient on a cardiac monitor with pulse oximetry / PC, MK, PBL
Obtains a bedside ECG / PC, MK, PBL
Places the patient on supplemental oxygen / PC, MK, PBL
Performs a full neurological exam / PC, MK, PBL
Performs a hearing test / PC, MK, PBL
Orders a CT scan to rule out acute intracranial pathology / PC, MK, PBL, SBP
Places a peripheral IV / PC, MK, PBL
Draws labs to evaluate for metabolic disturbances, infections, and endocrine or hormonal abnormalities contributing to the symptomatology. / PC, MK, PBL, SBP
Elicits a history of vertigo, tinnitus, and hearing loss from the patient and makes the diagnosis of Meniere’s Syndrome. / PC, MK, ICS, SBP
Obtains a neurological consult to aid in patient disposition. / PC, MK, ICS, SBP
Category: One or more of the ACGME Core Competencies as defined in the SDOT