Neurology Clerkships
Case 15  
Author: Eric Kraus, MD
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This is a 52 year-old female who is referred by Dr. Smith for dizziness. Onset was 6 days ago. She was getting out of bed when she felt dizzy and was thrown back into bed. Since then she has had 6 events all when turning her head to the right. Two while getting out of bed on the right side and four in the car when trying to back out of the driveway. The dizziness is described as spinning with the environment moving counterclockwise. The duration is 1 minute, but she feels unsteady for at least an hour afterwards. Her hearing has been declining for the last 2 years. A low level tinnitus is present at night. No ear pain, head trauma or diplopia. She denies all other neurologic ROS. A different dizziness occurred two years ago when she tried Paxil.

The main worry today is that her father describes the same feeling and has been diagnosed with Meniere’s disease. The dizziness incapacitates him.

1. Depression
2. Hysterectomy
3. Osteoarthritis
4. HTN
5. DM II
6. Hyperlipidemia

1. Effexor 150mg qd
2. Prevacid
3. Zocor 20mg qd
4. Lisinopril 10mg qd
5. HCTZ 25mg qd
6. Glipizide
7. Vioxx
8. MVI

Allergies: Sulfa, PCN, Paxil

Family History: HTN, DM II, and hyperlipidemia in multiple members. Father has Meniere’s disease.

Social History: Executive at a software company. 2 children. Married. Rare alcohol. No smoking.

BP 162/94   HR 102   T 36.5°C
General: Alert. Thin.
Mental Status: A + Ox3
HEENT: Atraumatic. PERRLA, EOMI, no nystagmus at baseline. Fundi reveal sharp discs with good venous pulsations. Face is normal to motor and sensory exam. Nose normal. Hearing mildly reduced to finger rub bilaterally. External canals normal. TMs good. OP normal. The Hallpike maneuver was normal to the left side. To the right side she had a geotropic rotational and upbeat nystagmus after delay of two or three seconds. It lasted probably 15 to 20 seconds total and then went away.
Motor (Power/Tone/Bulk): 5/5 all. Normal tone and bulk.
Sensory: Normal vibration at the toes.
Reflexes: 2/4 at biceps, triceps and ankles, 1/4 at brachioradialis and knees. Both toes downgoing.
Coordination: Left tremor with FNF. HKS normal.
Gait: Narrow based.
Abnormal Movements: Mild action tremor in the left hand.
Other Organs: Carotid auscultation normal. RRR w/o murmur.

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