Hot Seat #175: Denouement

Posted on: September 17, 2021, by :

This week’s case focuses on the approach to a patient with vertigo. We polled the group regarding their initial laboratory workup in a stable patient with vertigo and found a range of responses. Many opted for a minimal workup including no testing or just a covid test. Fewer chose to send some basic laboratory evaluation like a CBC and CMP or inflammatory markers, and a small minority in both groups chose to perform an EKG.

The proportion of respondents choosing to get brain imaging was similar in both groups, but a majority did not say they would get either a head CT or refer for an outpatient MRI. Slightly more of the junior respondents opted for an emergent head CT (38%) than the senior respondents (27%). Junior respondents were also more likely to opt for a neurology consult (46%) than senior respondents (25%). However these proportions were similar in regards to a patient with a more severe presentation and difficulty ambulating unassisted (64% to 71%).

Vertigo is not a common presenting complaint in the pediatric emergency department, which may explain why there is such a high degree of variability in respondents’ chosen approach above. In particular, only a minority of respondents elected to pursue emergent brain imaging. Much of our discussion focused on the utility of an emergent head CT in an otherwise well appearing patient. And while it could diagnose some cerebellar infarcts or brainstem disease, it is not a particularly sensitive test, especially in a patient of this age and without other risk factors for stroke. Ultimately the group remained largely opposed to emergent head CT.

After discharge, this patient continued to have intermittent dizziness and we seen in our otolaryngology outpatient clinic. There, an audiogram was normal and it was recommended that the patient follow-up with our Balance Clinic for further workup.

Walter Palmer

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