What’s Your Diagnosis? Patient With Acute Dizziness

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Case Presentation: A previously healthy man with dizziness

The day shift signs out to you a 44-year-old previously healthy man. He is currently at CT.

His dizziness started 6 hours previously and has been present ever since. He describes unsteadiness and ?feeling like I am drunk,? and has vomited 3 times. He denies headache or neck pain, weakness, or numbness. His vital signs are normal. There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze. The head impulse test is normal.

The sign-out is that if his CT scan is normal, he can go home with meclizine and follow-up with his PCP in 2 days.

That sounds reasonable, but you wonder if there is something else that needs to be considered…

Case Conclusion

You are NOT OK with the plan for discharge if the man?s CT is normal. His CT was normal, but sensitivity of noncontrast head CT in early posterior circulation stroke is very low and a negative CT should never reassure physicians that they have ruled out ischemic stroke. The absence of a report of ?vertigo? is diagnostically meaningless. Although his nystagmus is consistent with a peripheral problem, it is also consistent with a central problem, so completing the bedside examination for a patient with an AVS is important. Calling the HIT ?normal? is also problematic. ?Normal? means the absence of a corrective saccade, which in the setting of the AVS is worrisome for stroke. Better terminology would be that HIT is ?worrisome? or ?reassuring,? and better yet, ?absence or presence of a corrective saccade.? Since physical examination
is more sensitive than even early MRI for posterior circulation stroke presenting as isolated dizziness, this patient was admitted for a stroke workup.

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Last Updated on January 26, 2023

EB Medicine