About Stephanie Lareau, MD, FACEP, FAWM

Associate Professor
Dept. of Emergency Medicine
Virginia Tech Carilion School of Medicine

SAEM Clinical Images Series: I Cannot Control My Right Side

The patient is a 47-year-old female whose past medical history includes ESRD on dialysis, type 1 diabetes, and hypertension, who presents to the Emergency Department for uncontrollable right-sided movements of her body. The patient states these symptoms have been present for several weeks and have progressively worsened over the past week. She reports difficulty with ambulation secondary to these involuntary movements of the right side of her body. She denies any missed dialysis sessions. She denies fever, headaches, sensory problems, or any other complaints at this time.

Physical Exam

Vitals: BP 201/88 HR 92 R 18 T 97.5 O2sat 99% room air.

General: Awake and alert, no acute distress.

Cardiovascular: Regular rate and rhythm with no murmur. Right upper extremity fistula with good thrill and no signs of infection.

Neurologic: GCS 15, moving all four extremities well. Cranial nerves intact, but repetitive twitching of the right side of the face is seen on examination. There are repetitive jerking movements of her right upper and right lower extremity. Sensation intact and equal bilaterally.

Laboratory Data

CMP:

Na 127
K 4.5
Cl 92
HCO3 25
BUN 24
Creat 5.5
Glucose 540

Case Question: What does the CT show?

Hyperintensity along the left lentiform nucleus.

Case Question: What is the diagnosis?

Hemichorea-Hemiballismus Syndrome.

Case Discussion

There is a stripe of hyperintensity along the left lentiform nucleus seen on head CT, which is a finding consistent with hemichorea- hemiballismus syndrome. This syndrome is a rare presentation that can occur in the setting of acute hyperglycemia or uncontrolled diabetes. Patients with hemichorea-hemiballismus syndrome typically present with involuntary movements of upper and lower limbs, usually unilaterally, but in even more rare cases bilateral symptoms may occur. Neuroimaging may show hyperintense lesions along the contralateral striatum of the affected extremities. Proposed pathophysiology of this syndrome includes hyperviscosity secondary to hyperglycemia and disruption of the blood- brain barrier, decrease in GABA availability in the striatum, and hypersensitivity of the dopamine system receptors due to decreased estrogen concentration in postmenopausal women. Treatment includes management of hyperglycemia; neurological symptoms typically resolve with glycemic control.

Take-Home Points

Hemichorea-hemiballismus syndrome can occur in the setting of hyperglycemia and uncontrolled diabetes, and it typically presents with unilateral involuntary movements of the body.
Neurological symptoms resolve with management of hyperglycemia and improved glycemic control.

References

Dong M, E JY, Zhang L, Teng W, Tian L. Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review. Front Neurosci. 2021;15:690761. Published 2021 Jun 23. doi:10.3389/fnins.2021.690761
Salem A, Lahmar A. Hemichorea-Hemiballismus Syndrome in Acute Non-ketotic Hyperglycemia. Cureus. 2021;13(10):e19026. Published 2021 Oct 25. doi:10.7759/cureus.19026

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Stephanie Lareau, MD, FACEP, FAWM|2025-12-16T22:35:25-08:00Dec 19, 2025|Emergency Medicine, Neurology, SAEM Clinical Images|

How I Educate Series: Stephanie Lareau, MD

This week’s How I Educate post features Dr. Stephanie Lareau, the Wilderness Medicine Fellowship Director and Medical Director of Emergency Services at Virginia Tech Carilion Clinic. Dr. Lareau spends approximately 50% of her shifts with learners which include emergency medicine residents, off-service residents, and medical students. Her practice environment is split between an academic and community hospital. She spends 25% of her time at the academic level 1 trauma center that is home to an EM residency and medical school. The other 75% of her clinical shifts are at a 12-bed community ED which also has both resident and student learners. Below she shares with us her approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Acuity, black cloud.

What learning theory best describes your approach to teaching?

There can be more than one right way to approach a complaint. I like to give learners a chance to develop their approach, not try to “think what this attending would do”. I try not to jump in too early, unless it’s a critical situation, to change the learner’s plan.

What is one thing (if nothing else) that you hope to instill in those you teach?

Remember the patients are people, who have mothers and children. It’s easy to get jaded in our practice environment, but humanizing the people we care for, makes us care. Patients can tell when we actually care.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

I try to see the patients with less teaching potential primarily and encourage the residents to see the more interesting and complicated patients. This seems to keep the department moving. I also try to steer the residents from just signing up for everyone – things flow better if I see some primarily too. For medical students, I try to steer them to things that are a bit more straightforward. Sometimes I’ll go with the residents to see patients, especially non-english speaking ones.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Not putting on sterile gloves during a procedure keeps me from jumping in too quickly. If they struggle I joke they’ll get it before I can put gloves on – and sometimes they do!

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

Depending on the learner sometimes I’ll ask if they have objectives, typically more for the medical students. Usually, with residents, the patients will provide learning points.

Do you typically see patients before or after they are presented to you?

Typically see patients after they are presented to me, in our environment attending also see patients independently, so if I find something interesting or someone critically ill I often “share” these encounters with residents.

How do you provide learners feedback?

I try to provide feedback in the moment or verbally after the shift. Timely feedback makes a bigger impression than reading evals days later.

Are there any resources you use regularly with learners to educate during a shift?

I encourage learners to look up things on shift that they don’t know. Sources vary – anything from Corependium to PubMed to Emedicine – I like to see what resources learners go to first and why.

What are your three favorite topics to teach during a shift?

DKA, Hypothermia, really any environmental emergency.

What is your favorite book or article on teaching?

Make it Stick – a great book to examine how we learn, which helps improve teaching

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Stephanie Lareau, MD, FACEP, FAWM|2022-10-26T10:34:33-07:00Oct 26, 2022|How I Educate, Medical Education|