Hot Seat #175: 16-year-old with vertigoPosted on: September 3, 2021, by : Walter Palmer
Malek Mazzawi, MD, Children’s National Medical Center
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.
FH: No family history of neurologic disorders. No family history of migraines or vertigo.
SH: Denies substance use.
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
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.
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