Jordan Smedresman SUNY Downstate College of Medicine Class of 2013

 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

 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

 WBC: 9.3  Hb: 12.4  Hct: 40.6  Plt: 344  MCV: 65  β -HCG: 0  T4: 1.18  TSH:  Na: 141  K: 4.2  Cl: 104  CO2: 26.6  BUN: 14  Cr: 0.6  Glucose: 104  Ca: 10.2

 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)

 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

 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