Journal article: ER should treat for stroke if patient has dizziness and difficulty walking or standing

I met with an emergency medicine expert today to discuss a medical malpractice case that Painter Law Firm is currently investigating in the Houston area. Because Texas law requires medical malpractice plaintiffs to have a medical expert report early in the litigation process, our practice is to consult with medical experts before a lawsuit is filed.

The particular case that we were discussing involves a patient who went to a hospital emergency room because of severe dizziness, accompanied by nausea and vomiting. At first glance, general symptoms like dizziness and headaches may be discounted as insignificant because they could be consistent with many different types of injuries or conditions.

A recent peer-reviewed article in the journal Annals of Emergency Medicine reviews the standard of care for diagnosing patients with sudden development of persistent dizziness.

As it turns out, dizziness is a common cause for presentation to an emergency room, accounting for about 3% the patient visits. Physicians and nurses need to ask precise questions, focusing on how rapidly the dizziness began, whether their associated symptoms, and whether it comes and goes or is constant.

This information is important because some types of dizziness are harmless, but others can indicate a life-threatening condition. The journal article focused on one type, a sudden onset of severe persistent and continuous dizziness associated with nausea, vomiting, and instability in walking or standing.

The Harvard physician who wrote the article recommended that healthcare providers ask patients with acute-onset persistent dizziness the following five questions.

The first question is whether there is a central pattern of nystagmus. Nystagmus is a condition where the eyes make repeated uncontrolled moves. It is tested by observing eye movements.

The second question is whether a skew deviation is present. Skew deviation is another eye issue, where the eyes move upward, but in opposite directions.

The third question is whether the head impulse test is negative. This one only applies to patients with a nystagmus.

The fourth question is whether there any central nervous system signs on a focused neurological exam.

The fifth, and final, question is whether the patient is unable to sit or walk unassisted.

If the answer is “yes” to any single question, then the patient should be treated for stroke. That treatment would include ordering a consultation with a neurologist, ordering brain and cerebrovascular imaging, admitting the patient to the hospital for a stroke workup, and beginning secondary stroke prevention. The likely imaging would include tests like an MRI or MR angiogram, designed to rule out a vertebral artery dissection.

In this case that we are currently reviewing, the emergency room physician and nurses unfortunately did not ask these five questions. If they had, the first four answers would be “no,” but the last one would be a resounding “yes.” When the patient came to the emergency room, he had to be transferred into the hospital by wheelchair because he had a total lack of balance. When he was discharged a few hours later, he walked out with significant support from his wife on one side and holding his hand against the wall on the other.

The next day, he returned to the hospital and was promptly diagnosed with a stroke. Stroke medical and nursing experts that we have consulted concluded that this patient was already experiencing the beginning of the stroke the prior day when he first went to the emergency room. Even though the emergency room physician and nursing staff had all the information in front of them, and even documented in the medical records, the patient was inappropriately misdiagnosed and discharged.

If he had been treated within the standard of care, his permanent injuries that will keep him from being able to work for the rest of his life would likely have been avoided.

We are here to help

If you or a loved one has been seriously injured by hospital, nursing, physician, or surgical care, then the experienced medical malpractice attorneys at Painter Law Firm, in Houston, Texas, are here to help. Click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.

All consultations are free and, because we only represent clients on a contingency fee, you will owe us nothing unless we win your case. We handle cases in the Houston area and all over Texas. We are currently working on medical malpractice lawsuits in Houston, The Woodlands, Sugar Land, Conroe, Dallas, Austin, San Antonio, Corpus Christi, Bryan/College Station, and Waco.


Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.