Author: Jennifer Johnson, MD
Co Author #1: Eliot Young, MD
Editor: Young Yoon, MD
The patient is a 14 year old male football player with a three month history of dizziness and mood swings, noting an acute exacerbation of symptoms after a hard head-to-head hit during football practice two weeks prior to presentation.
The patient presents to the sports medicine clinic for a concussion evaluation. He states that he has been intermittently dizzy for approximately three months. The dizziness began insidiously, with no identifiable inciting event. Although the dizziness has been gradually worsening in terms of frequency and severity, it has not interfered with his activity. He has continued to play football despite his symptoms. The patientâ€™s parents state that he has also been having mood swings for the past few months, but they attribute this to normal teenage behavior. Within the last three months, he has had two discrete episodes of profound dizziness.
The first episode occurred two weeks prior to presentation. The patient recalls sustaining a particularly hard head-to-head hit during freshman football practice. Although he suffered no loss of consciousness and continued to practice after the hit, he did complain of an exacerbation of dizziness for the following two days. On the second day, while he was acting as a ball boy for a varsity football game, he was acutely overcome with dizziness and collapsed on the sidelines. Although he never lost consciousness, he did have clonic head deviation to the left and bilateral arm flexion posturing. The entire event lasted about 1 minute, and he was verbally responsive the entire time. The patient was immediately taken to the emergency room via ambulance. He received a liter of IV fluids en route. Lab work was consistent with dehydration. By the time the patient was discharged from the ER, dizziness had improved and he was without any post-ictal symptoms. Three days after the event, he was cleared by his pediatrician to return to football with a diagnosis of resolved dehydration.
The second episode of acute dizziness exacerbation occurred one week after the first episode and one week prior to presentation. The event occurred while the patient was casually visiting friends. Without provocation, the patient suddenly had slurred and nonsensical speech. The patient became irritable and uncooperative and attempted to remove his own shirt. The abnormal speech and behavior lasted approximately one to two minutes. The dizziness, although improved after two minutes, persisted until presentation at the sports medicine clinic.
- General: Pleasant adolescent male, alert, oriented to person, place, and time
- HEENT: PERRL, EOMI, tympanic membranes clear, hearing intact bilaterally, nares clear, oropharynx clear with no erythema or tonsillar enlargement.
- Neck: Thyroid normal size and symmetrical with no masses, neck supple, no cervical lymphadenopathy
- Cardiovascular: RRR, normal S1 and S2, no gallops or murmurs, radial pulses 2+ bilaterally, capillary refill less than 2 seconds
- Lungs: Clear to auscultation bilaterally, no wheezes or crackles, normal work of breathing, normal excursion
- Abdomen: Soft, nontender, no hepatosplenomegaly
- Neurologic: Normal level of consciousness, normal intellect, remote memory intact, working memory intact, delayed recall intact, concentration good, reasoning good, cranial nerves II-XII grossly intact, finger to nose intact, heel to shin intact, rapid alternating movements intact, normal gait, balance normal (rhomberg, tandem rhomberg, one leg stand), strength 5/5 bilateral upper and lower extremities, deep tendon reflexes 2+ bilaterally upper and lower extremities, sensation grossly intact throughout
Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.