DIZZINESS IN THE EDJordan Smedresman

SUNY Downstate College of Medicine Class of 2013

30 year old woman with “dizziness”

Suddenly started ~6 hours prior to evaluation when she stood up after dinner

Felt the room spinning, had to be supported to keep from falling

Nausea , one episode of vomiting Similar episode one week prior,

spontaneously resolved after “a few hours” No history of trauma, no recent illness, no

tinnitus Still unsteady on her feet, but gradually

improving, nausea has resolved

PMH—anemia PSH—c-section 7 years ago Allergies—shellfish (rash), no drugs Meds—iron, Centrum

Temp 98.2, HR 86, RR 16, 178/107 (repeat 150/100)

Physical exam unremarkable

Neuro Exam

Alert and oriented x3 CN II-XII intact, slight horizontal nystagmus

upon turning the head, worse when turning left

Muscle strength 5/5 in all extremities, normal sensation

Reflexes 2+ throughout FTN intact Gait unsteady, not ataxic Upon lying flat, symptoms returned Patient refused Dix-Hallpike test

Labs

WBC: 9.3 Hb: 12.4 Hct: 40.6 Plt: 344 MCV: 65 β-HCG: 0 T4: 1.18 TSH: 1.792

Na: 141 K: 4.2 Cl: 104 CO2: 26.6 BUN: 14 Cr: 0.6 Glucose: 104 Ca: 10.2

Benign Paroxysmal Positional Vertigo

Usually multiple short (seconds) episodes reproduced by tilting the head

Often caused by canaliths Can last weeks to months Vomiting is rare Diagnosed through history. Dix-Hallpike

can helpful (50-80% sensitive)

Canalith Repositioning

Vestibular Neuronitis

Believed to be viral or postviral inflammatory disorder

Rapid onset of severe, persistent vertigo with nausea/vomiting and gait instability (fall toward affected side)

Spontaneous nystagmus Clinical diagnosis Usually lasts 1-2 days

This patient

Time course—vestibular neuronitis Suggestive setting—BPPV (more

predictable head movements, no recent illness)

Nystagmus—more typical of vestibular neuronitis

Treatment—meclizine with ENT followup Second line—benzos