A 33-Year-Old Man Suddenly Unable to Stand or Sit

Olusegun John Oluwole, MBBS

Disclosures

February 14, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 33-year-old man is brought to the emergency department owing to sudden onset of severe vertigo, vomiting, and loss of balance, which had begun 2 days earlier. He had been in the kitchen preparing his breakfast when he suddenly felt dizzy, lost his balance, and fell on the floor. He did not hit his head on the floor during the fall.

From that time onward, the patient has experienced a constant spinning sensation and had become unable to sit or stand without support. During questioning, he reports several episodes of vomiting that occurred both spontaneously and in association with any head movements, as well as persistent numbness in the left half of his face. In addition, he reports a mild to moderate left-sided occipital headache and ill-defined neck pain. He reports no clouding of consciousness, neck stiffness, or photophobia; however, he was reluctant to open his eyes because of a perception of continuous spinning.

The patient denies any prior manipulation of his neck or any recent strenuous physical activity. He reports no seizures nor weakness in any of his limbs. He has not had double vision, blurring of vision, or temporary loss of vision. He has not experienced swallowing difficulty or hoarseness. He denies any hearing loss or tinnitus and reports no recent upper respiratory tract infection. He does not have a previous history of similar attacks of dizziness or vertigo and reports no fever, ear pain, or ear discharge. He has had no prior head or neck trauma and had been generally well until the onset of his symptoms 2 days prior.

His past medical history is positive for systemic hypertension diagnosed 5 years earlier, and he has not regularly taken his antihypertensive medications. To his knowledge, no known secondary etiologies have been identified for his hypertension. His father also has hypertension; however, he has no known family history of neurologic disease. He is not a smoker and reports no alcohol abuse or use of any illicit drugs.

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