Severe Dizziness, Nausea, and Vomiting Prompt an ED Visit
Mr. W, aged 57 years, presented to the ED complaining of severe dizziness. The man reported that the disequilibrium was with him when he woke up two days ago and was accompanied by vomiting. Mr. W thought the feeling of unsteadiness would go away, but it had not abated. Moving his head or opening his eyes made the dizziness worse.1. HISTORY
Mr. W was not taking any medications. During consult, Mr. W noted recently battling sinus congestion and an accompanying headache behind his left eye. He had used a Neti pot for relief. No recent fever, ear problem or tinnitus were reported, and Mr. W had no history of dizziness or head or neck trauma. There was no family history of heart attack, stroke or diabetes.
Mr. W was afebrile, and his BP was normotensive (117/71 mm Hg). Pulse was 60 beats per minute and respiration 16 breaths per minute. Mr. W was alert and oriented. Ear, nose and throat all appeared normal. Cranial nerves II through XII were all intact. Horizontal nystagmus to the left was noted, and the Dix-Hallpike test was mildly positive. Finger-to-nose and heel-to-shin movements were normal. Mr. W had no pronator drift. Deep tendon reflexes were a normal 2+ throughout. Mr. W was able to stand at the side of the bed and had a negative Romberg test. Musculoskeletal strength was 5/5 in all four extremities with no numbness or tingling anywhere.
3. DIAGNOSIS AND TREATMENT
Mr. W was given promethazine (Phenergan) to control the nausea and vomiting. Complete blood count and electrolytes came back normal 45 minutes later. Although Mr. W's orthostatic vital signs were normal, a neurological exam was repeated, showing no real changes. As the Dix-Hallpike test was not convincing for vertigo, a CT scan of the head was ordered. The CT was negative for a bleed.
As Mr. W tried to walk, staff noticed that his gait was severely affected. A subsequent MRI revealed that Mr. W had an acute left cerebellar infarction. A magnetic resonance angiogram of the head and neck was ordered showing a vertebral artery dissection in the C1-C2 area. He was diagnosed with a cerebellar stroke causing acute vestibular syndrome (AVS).
Mr. W was admitted to telemetry and placed on aspirin. Lipids, carotids, and all other workups were negative. Mr. W was discharged two days later and able to walk without assistive devices after physical and occupational therapy. Within two weeks, Mr. W's gait had returned to normal.