This is a 62 year-old female who is referred by Dr. Smith for dizziness.
Onset was 6 months ago. The dizziness is described as spinning with the
environment moving from right to left. Two episodes have occurred. The
first lasted 2 hours and the second 8 hours. Today she is not dizzy. Neither
event was precipitated by movement, but they were preceded by a pressure
feeling in the right ear. During the dizziness she has N/V and needs to
stay in bed. Her hearing in the right ear has been declining for the last
2 years. A roaring tinnitus started one month ago also on the right. No
ear pain, head trauma or diplopia. She denies all other neurologic ROS.
Twenty years ago she had 3 weeks of dizziness after a car accident.
2. Breast cancer treated 1998
7. Whiplash 1983
1. Paxil 20mg qd
2. Omeprazole 20mg qd
3. Zocor 20mg qd
5. HCTZ 25mg qd
Allergies: Colchicine, Keflex
Family History: Hyperlipidemia in multiple members.
Father has peripheral neuropathy. Mother died of breast cancer age 64.
Social History: Retired. 4 children. Married. Rare alcohol.
BP 162/94 HR 102
General: Alert. Thin.
Mental Status: A + Ox3
HEENT: Atraumatic. PERRLA, EOMI, no nystagmus. Fundi
reveal sharp discs with good venous pulsations. Face is normal to motor
and sensory exam. Nose normal. Hearing moderately reduced to finger rub
on the right. External canals normal. TMs good. OP normal. The Hallpike
maneuver was normal to both sides. Vestibular past-pointing normal.
Motor (Power/Tone/Bulk): 5/5 all. Normal tone and bulk.
Sensory: Reduced vibration at the toes consistent with age. Increased
sway on Romberg.
Reflexes: 1/4 at biceps, triceps, knees, and ankles.
0/4 at brachioradialis. Both toes downgoing.
Coordination: Bilateral tremor with FNF. HKS normal.
Gait: Narrow based. Moderately poor heel-to-toe walk.
Abnormal Movements: None.
Other Organs: Carotid auscultation normal. RRR with 2/6
systolic murmur at the ULSB.