Continuous vertigo with vascular risk factors, worked until stroke is excluded: HINTS findings recorded one by one, gait graded, exam limits stated, vestibular neuritis concluded. Searches like "nu 552 unit 8 assignment example", "nu552 unit 8 sample" and "nu552 unit 8 example" land here.
Keeping Stroke in Front: A Red Flag Case Study of Continuous Vertigo in a 63-Year-Old With Vascular Risk
[Student Name]
Purdue University Global
NU552: Advanced Health Assessment and Diagnostic Reasoning
Unit 8 Assignment
[Instructor Name]
[Date]
The patient is a composite built for the case study; no real patient is described.
Presentation
Ms. [G.], 63, owns a flower shop. She woke at 5 a.m. with the room spinning, and it has not stopped in the fourteen hours since. The spinning is continuous, present at rest and worse, but not triggered, when she moves her head. She has vomited four times. She can walk only with a hand on the wall. She has hypertension, treated with amlodipine, and type 2 diabetes, treated with metformin. She has not had a similar episode before.
She has no change in hearing and no ringing in either ear. She has no headache or neck pain, no double vision, no difficulty speaking or swallowing, and no numbness or weakness in her face or limbs. A quick neurological screen in triage, checking arm and leg strength, facial symmetry and speech, was normal.
Her presentation is an acute vestibular syndrome: continuous vertigo lasting more than a day or so, with nausea or vomiting, unsteady gait and nystagmus, in someone who was well before. The two leading causes are vestibular neuritis, an inflammation of the vestibular nerve, and a stroke in the posterior circulation, most often in the cerebellum or brainstem.
The Red Flag and Why It Hides
Stroke ranks first on danger and is named here first, even though vestibular neuritis is more likely in most patients with this syndrome. A cerebellar stroke that is missed can swell, compress the brainstem and kill, and it can be followed by a larger stroke that treatment might have prevented. Ms. [G.]'s age, hypertension and diabetes put her at real vascular risk.
The red flag hides because posterior circulation strokes that cause isolated dizziness often spare the pathways that the quick neurological screen tests. A small stroke in the inferior cerebellum can produce vertigo, vomiting and imbalance without any weakness, numbness or speech disturbance. A normal quick neurological screen does not exclude a stroke in a patient with acute vestibular syndrome, because it examines the wrong parts of the brain. Studies of the bedside examination in these patients show that the general neurological examination misses a substantial share of strokes (Tarnutzer et al., 2011).
The Exclusion: HINTS Examination
The HINTS examination has three parts: the head impulse test, the pattern of nystagmus and a test of skew. In the original study, in patients with acute vestibular syndrome and at least one stroke risk factor, a HINTS examination with any central finding had a sensitivity of about [100] percent and a specificity of about [96] percent for stroke (Kattah et al., 2009). Each component is recorded below beside the finding that would have signaled a central cause.
Head impulse test.
1. Finding: to the right, a corrective saccade; the eyes were carried off target with the head and snapped back. To the left, the eyes stayed on target.
2. Meaning: an abnormal head impulse on one side indicates a peripheral vestibular lesion on that side. This is reassuring.
3. Central finding would have been: a normal head impulse in both directions in a patient with continuous vertigo. That is a dangerous finding, because in acute vestibular syndrome a normal head impulse suggests the vestibular nerve is working and the problem is in the brain.
Nystagmus.
1. Finding: horizontal nystagmus beating to the left, present in all directions of gaze, stronger when looking left, and not changing direction when she looked right.
2. Meaning: direction-fixed horizontal nystagmus, beating away from the side of the abnormal head impulse, is the peripheral pattern.
3. Central finding would have been: nystagmus that changes direction with gaze, beating right on right gaze and left on left gaze, or purely vertical or torsional nystagmus.
Test of skew.
1. Finding: on alternate cover testing, no vertical correction of either eye.
2. Meaning: no skew deviation.
3. Central finding would have been: any vertical refixation when the cover moves, indicating a vertical misalignment of the eyes from a brainstem or cerebellar lesion.
Gait.
1. Finding: unsteady, broad-based but possible unaided, with a tendency to veer to the right.
2. Meaning: consistent with a peripheral lesion.
3. Central finding would have been: inability to stand or walk unaided, which is more common in cerebellar stroke.
The Limits of the Figures
The accuracy figures come from a study in which the examinations were performed by neuro-ophthalmologists and neurologists with specific training in eye movement examination (Kattah et al., 2009). Clinicians without that training may be less accurate, especially in interpreting the head impulse test, which is the component most often misread. The figures are therefore an upper bound for a less experienced examiner.
Early imaging is not a reliable substitute. Computed tomography is poor at showing posterior circulation strokes. Even diffusion-weighted magnetic resonance imaging, the most sensitive imaging, missed about one in eight strokes in the first 48 hours in the same study (Kattah et al., 2009). A normal early scan does not exclude stroke when the bedside examination suggests one.
Risk scores do not substitute for the examination either. In a later cohort of patients with acute continuous vertigo or dizziness, the HINTS examination identified stroke far better than the ABCD2 score, a tool built to predict stroke after transient ischemic attack; many strokes occurred in patients whose ABCD2 score would have labeled them low risk (Newman-Toker et al., 2013). The same investigators added a bedside test of new hearing loss, since a stroke affecting the inner ear's blood supply can produce a peripheral-looking head impulse with new deafness. Ms. [G.] reported no hearing change, and finger-rub hearing was symmetric.
HINTS also applies only to acute vestibular syndrome. It is not designed for positional or episodic vertigo, and in those settings a normal head impulse is expected and not dangerous.
Conclusion
With a unilateral abnormal head impulse, direction-fixed horizontal nystagmus beating away from that side, no skew and a gait that is unsteady but possible, the HINTS examination points to a peripheral cause, and the working diagnosis is vestibular neuritis on the right. Stroke is excluded as far as a bedside examination allows.
The exclusion holds only under stated conditions:
1. New neurological signs, such as double vision, difficulty swallowing, slurred speech, facial numbness or limb weakness, would reopen the question at once.
2. New hearing loss would reopen it, because sudden hearing loss with vertigo can come from an infarct of the inner ear supplied by the anterior inferior cerebellar artery.
3. A new headache, particularly in the back of the head, would reopen it.
4. Failure to improve over several days, or an inability to walk that does not ease, would call for imaging and a neurological consultation.
These conditions are recorded in the discharge plan and explained to her and to her daughter, who will stay with her tonight.
References
Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504-3510. https://doi.org/10.1161/STROKEAHA.109.551234
Newman-Toker, D. E., Kerber, K. A., Hsieh, Y.-H., Pula, J. H., Omron, R., Saber Tehrani, A. S., Mantokoudis, G., Hanley, D. F., Zee, D. S., & Kattah, J. C. (2013). HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Academic Emergency Medicine, 20(10), 986-996. https://doi.org/10.1111/acem.12223
Tarnutzer, A. A., Berkowitz, A. L., Robinson, K. A., Hsieh, Y.-H., & Newman-Toker, D. E. (2011). Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. Canadian Medical Association Journal, 183(9), E571-E592. https://doi.org/10.1503/cmaj.100174
How this NU552 Unit 8 example is structured
The case is built to keep a dangerous hypothesis alive until evidence, not reassurance, removes it. Stroke is named in the opening paragraph and ranked first for danger though judged less likely, and every later section addresses it directly. Each HINTS component appears beside the finding that would have signaled a central cause: a normal head impulse in a patient with continuous vertigo, direction-changing nystagmus, or any skew. That paired format makes the exclusion checkable. Accuracy figures from the cited study are bracketed, and the paper stresses that they come from examiners with specific training. Early imaging is discussed honestly, false negatives included. The conclusion is conditional: stroke is excluded as far as an examination allows, and new neurological signs top the list of what would reopen the question.
Get an NU552 Unit 8 example written to your instructions
Red flag cases vary widely by section, from headache to chest symptoms to a painful back. Send the NU552 Unit 8 case your section issued and its rubric. Written to your instructions and returned in 24-48h without cost on a first order, the case study keeps the dangerous cause in view until specific, documented findings exclude it. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
NU552 Unit 8 questions, answered
Does the case need the HINTS exam specifically?
Only when the presentation is acute continuous vertigo, the setting HINTS was studied in. Other red flag cases use their own discriminating findings: neck stiffness and rash for meningitis, saddle anesthesia for cauda equina. The sample's method, pairing each finding with the result that would have alarmed, transfers to whatever case the section assigns.
Can a red flag ever be fully excluded by examination?
Sometimes nearly so, rarely absolutely. The sample concludes that stroke is excluded as far as a trained bedside examination allows and lists what would reopen the question. Instructors in reasoning courses typically reward that conditional honesty over a confident conclusion the evidence cannot fully support.
How should accuracy figures for a bedside test be reported?
With their source and the conditions they were measured under. The sample brackets HINTS figures and notes they come from examiners with specific training, which matters because performance falls in less experienced hands. Quoting a figure without that caveat implies a certainty the literature does not claim.