jmj11 Posted October 25, 2015 Share Posted October 25, 2015 This is a true case and I wonder what you seasoned ER folks think. 26 yo health male awakens in the middle of the night with low grade (99.8) fever, intense vertigo, nystagmus, severe headache, nausea and vomiting. The symptoms persist unchanged, except for the temp returning to normal by day three. On day five, the first day he can stand (slight decrease in the vertigo but intense headache persist), he goes to the ER and is seen in a fast track. He was seen by the PA and dx as benign positional vertigo and given Epley-type exercises for home. Agree? Disagree? Differential? What do you think? Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted October 25, 2015 Moderator Share Posted October 25, 2015 I'm family medicine, but do plenty of urgent care type work since I'm attached to a hospital. Disagree. BPPV doesn't last that long and should fatigue with repetition. Could possibly be viral neuronitis. Unlikely to be stroke given age. What type of nystagmus? What does the head thrust test show? Can they walk? Given severe headache and in ED, I would scan. Could also be I am especially concerned when anybody tells me their symptoms woke them. Link to comment Share on other sites More sharing options...
MedicinePower Posted October 25, 2015 Share Posted October 25, 2015 Pressure worse while laying down but better when horizontal? I'm thinking meinere's disease should be on the ddx. Link to comment Share on other sites More sharing options...
jdenning Posted October 25, 2015 Share Posted October 25, 2015 What was this guy's exam like at the ER? History is atypical for benign positional vertigo Link to comment Share on other sites More sharing options...
Eastcoast PA-C Posted October 25, 2015 Share Posted October 25, 2015 It's definitely a decent story for something like a labyrinthitis, but the persistence/severity of the symptoms and the headache are worrisome enough that I would at the very least CT. Family history could be helpful. It would be weird, but a posterior circulation infarct or bleed would have to be in the differential (even though the CT is pretty lousy at evaluation the posterior fossa). Luckily I'm in a place where neuro is one phone call away and always willing to give some advice and arrange follow-up. In my shop, this guy probably gets an MRI (and probably wouldn't have been triaged to fast-track in the first place). I feel like sending this guy home without a workout would require some pretty impressive CYA documentation. How were the gait, cerebellar functioning tests and visual fields? Meningismus? Any meds given? After seeing strokes and MI's present to fast track, I tend to stay a little paranoid when working there. I'm especially suspicious when the benign diagnosis I'm considering doesn't quite fit, and I can make a decent case that it's something dangerous. Link to comment Share on other sites More sharing options...
Guest Paula Posted October 25, 2015 Share Posted October 25, 2015 I would worry about a viral or bacterial meningitis given the onset of a fever and headache. Or a basilar migraine? Not sure if that presents with a fever though. I see plenty of patients in PC with "BPPV" and they get that diagnosis AFTER I have run tests, EKGs, labs, etc. If I think they need a CT/MRi off to the ER they go. Did the patient have a recent travel history? Could he have a brain abscess? Sexual health history? What were his vitals? B/P especially and HR? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 25, 2015 Moderator Share Posted October 25, 2015 last time I checked you don't get fever with BPV. this guy probably needed a workup for meningitis and other badness with CT, labs, etc. I saw a guy like this a few years ago with HSV encephalitis. LP looked nl, but the viral culture was later +. He was still an inpt when the result came in. Link to comment Share on other sites More sharing options...
jmj11 Posted October 25, 2015 Author Share Posted October 25, 2015 Okay, here is the rest of the story. But first I will answer some questions. But I will comment, that this is my son. I know we should not come here seeking medical advice about family members and that is not what I am doing but presenting it as an interesting case. I was just perplexed by the Dx in the fast track, when I had a different impression. I saw him after the second day ( I wasn't aware that he was ill until his girlfriend called after 48 hours of illness) and he had resting nystagmus, fast component horizontal and lateral. Symptoms (vertigo and headache) were present even on resting. I took his temperature and it was the low-grade fever. His neck was supple. As a parent, I told him to go to the ER and get me out of the picture as a provider. Parents don't make good providers most of the time. He said he was too sick to get out of bed. I have him an IM injection of metoclopramide to help him with the nausea enough to go in. I will remind you that he is an adult, lives alone and makes his own decisions. We have never been helicopter parents. My sense that there was a virus in the mix and probably labyrinthitis. I considered a mild viral meningitis (he wasn't really "sick," meaning he was cognitively intact and alert) and was improving, though slightly. He finally went in on the fourth day (each day he was mildly better). He was fast tracked. He said he saw a young PA who spend 4-5 minutes with him, didn't do much of an exam and didn't ask any details about his history but only that he was still dizzy. Told him in confidence that it was BPV and sent him home with exercises. He is on a very slow road to recovery. My point being, I never considered BPV as a serious dx because of 1) came on in the middle of the night and was associated at first with chills and low-grade temp (could not be explained by a displace or "caught" otoconia) 2) had a rather severe headache, 3) was continuous even without movement (sounding more like an inflammation of the vestibular nerve rather than a mechanical obstruction), 4) constant nystagmus even with no movement at all and a very slow course of recovery. But what do I know? It makes me wonder, I know that we all can be unfairly critical as patients or as patient's family, but I think if I were the PA in urgent care, I would have gone over the history in some detail and just assume that vertigo = BPV. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 25, 2015 Administrator Share Posted October 25, 2015 The brief history doesn't meet the basic criteria of BPPV: vertigo with head movement, THAT STOPS. If it lasts for more than 15 seconds it's probably not, and if it lasts for more than a minute it's definitely not. When I send family members or friends to the ER, I give them a script of what I think are the most significant thinks to say. Even before I was an EMT, our younger son had a terrible case of croup (bad enough to get admitted) when he was a few months old, and my wife is a very compliant, nice kind of person who, if told to sit in triage and wait, would do so for hours. She's just not the kind of person to make a scene, and we picked me to stay home with the sleeping older son when she drove him POV to our local ED at about 0300. Before she left, I made her repeat back to me "my baby is having problems breathing" and promise that she would keep saying that until someone did something. She later told me that she hadn't even gotten the whole thing out of her mouth before they had her in a triage bay and a pulse ox on our son, and then the unit clerk eventually caught up with her to get our insurance information later. Triage USUALLY works just fine... but I still try to make sure everyone I love gets their succinct CC out first. Link to comment Share on other sites More sharing options...
jdenning Posted October 26, 2015 Share Posted October 26, 2015 I was actually wondering how anyone knew he had nystagmus before going to ER but now I understand that you saw him beforehand....:-) How did this turn out? I hope he's ok? Did he eventually get more workup? Link to comment Share on other sites More sharing options...
jmj11 Posted October 26, 2015 Author Share Posted October 26, 2015 I had sent him to the ER/Walk In clinic with my impressions and possible dx. Again, there is a time for parents to back away and let a un-involved professional look at the situation. I offered to go with him and my wife is the nursing director at the hospital where he went, but he went on his on time and without notifying us and that is okay, he is an adult. No work up. He is slowly recovering. I don't know if he returned to work today or not. I spoke to him Saturday, one week after the symptoms had started, and he was still quite weak. I think there is a lesson in listening. I know that insurance companies are my nemesis but they are pushing for shorter appointments, less testing, less listening and moving fast (by paying less and less for each visit). I don't think it is what is best for the patient. Not that anything they could have done could have helped my son better. Time is the treatment for this and not much else. Link to comment Share on other sites More sharing options...
winterallsummer Posted October 28, 2015 Share Posted October 28, 2015 Clearly this is not BPV given age and presentation. Viral meningitis or viral labrynthitis or even bacterial meningitis much more likely. Unless he looked like a million bucks he should've had basic labs and consideration of LP. IMHO. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.