Dizziness In The College Soccer Player

HISTORY: 21 y.o. male soccer player presents to the ER for acute onset dizziness for past 3 days. Objects in the room are overtly spinning. Dizziness is constant throughout day, but slightly improved while laying down. His dizziness is worse with sudden head movements or if he is up and ambulating. He began having nausea and vomiting 2 days ago. Now, he is struggling to walk due to feeling off-balance. His hands tingle while vomiting. He has subjective chills. He denies vision change, fever, headache, trauma, substance use, new medication, recent illness, or prior episodes similar to this. PHYSICAL EXAMINATION: BMI 22.9, BP 117/63, HR 65, T 97.7 F. He appears uncomfortable, vomiting into basin. A&Ox4. Answers questions and follows commands appropriately. PERRL, EOMI. Right beating nystagmus worst with rightward gaze, but also present in left gaze and spontaneous forward gaze, some in upward gaze. It does not change direction. Remainder of cranial nerves intact. Strength is 5/5 in all four extremities both proximally and distally. No pronator drift. Finger tapping is fast and symmetric. Sensation intact to light touch. 2+ reflexes throughout. No clonus. No dysmetria. Full neck ROM without pain, no TTP. Gait requires assistance by friend. DIFFERENTIAL DIAGNOSIS: BPPV, Vestibular Neuritis, Concussion, Vestibular migraine TEST AND RESULTS: CBC, CMP, and lipase notable for Glucose 124, Bilirubin 2.1, calcium 10.4, AST 36 (down trending from viral illness 2 months prior), anion gap 14 FINAL WORKING DIAGNOSIS: Vestibular Neuritis TREATMENT AND OUTCOMES: 1. In the ER, treated with Ativan 1 mg IV, Zofran 4 mg IV, 1 L bolus of LR.2. Neurology consulted and clinical presentation most consistent with a peripheral vestibular neuritis of L CN VIII. Recommended steroid burst and taper.3. Due to inability to tolerate PO, he was admitted for IV Solumedrol and observation. He transitioned to PO Prednisone the next day and treated symptomatically with Compazine.4. Inpatient PT evaluated and referred to vestibular therapy outpatient.5. At follow-up 5 days later, steroid course was complete and symptoms were improved with only slight dizziness when changing the position of head rapidly.6. He continued with HEP of vestibular therapy and gradually returned to activity starting with stationary bike. He had full RTP 16 days after onset of symptoms.