Hot Seat #175: 16-year-old with vertigo

Posted on: September 3, 2021, by :

Malek Mazzawi, MD, Children’s National Medical Center

HPI

16-year-old male with anxiety presents with 1 day of dizziness and a sensation of the room spinning. It began when he laid down in bed the night prior and now he has difficulty ambulating due to unsteadiness. Dizziness is constant with mild headache, no ear pain. Some nausea but no vomiting. Unable to sleep or sit still due to dizzy feeling. No recent fevers, cough or illness. No history of migraines. No weakness. No reported head trauma.

PMH: Anxiety

Meds: None

Allergies: None

FH: No family history of neurologic disorders. No family history of migraines or vertigo.

SH:  Denies substance use. 

ROS:

Constitutional: No fevers 

Skin: No rash

Eyes: No changes in vision, no blurred vision, no diplopia, no photophobia

ENTM: No ear pain, no changes in hearing, no sore throat, no tinnitus       

Respiratory: No SOB, no cough

GI: No abdominal pain. +Nausea, no vomiting or diarrhea

MSK: No neck pain, no back pain, no joint pain  

Neuro: +Headaches, +Dizziness, no LOC, no weakness, no paresthesias

Psychiatric: +Anxiety, +Sleep disturbance

PHYSICAL EXAM:

VS: Temp 38.6, HR 102, RR 20 BP 132/87, SpO2 100% on RA

General: Slightly anxious and fidgety but in NAD

Head and Neck: NCAT, supple neck, no nuchal rigidity, no lymphadenopathy

Eyes: PERRL, EOMI, normal vision, no nystagmus

ENMT: TMs difficult to visualize due to cerumen. MMM, posterior oropharynx clear

CV: Tachycardic but regular rhythm. No murmurs, cap refill <2s

Resp: CTAB, no wheezing, rales or rhonchi 

GI: Soft, NTND, no HSM

MSK: Normal ROM. No swelling.

Skin: No rashes

Neuro: Alert and oriented. CN II-XII intact. Normal sensory, strength and tone. Normal finger-to-nose test. Normal rapid alternating hand movements test. Slightly unsteady on Romberg. Normal gait including tandem walk and tip-toe walk. Negative Dix-Hallpike maneuver. No central ataxia while seated.

An EKG showed normal sinus tachycardia. He had COVID testing done which was negative. He received ibuprofen and an IV fluid bolus.  He defervesced, his HR normalized, and he was sent home with ENT follow-up if symptoms worsened.

3 days later, he presented again to the Emergency Department in the middle of the night with worsening symptoms. No longer febrile. His exam was unchanged and he was still able to ambulate without assistance. Head CT was done at this time which was negative. 

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Walter Palmer
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