Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 24-year-old man who has had vertigo for 12 hours which has prevented him from going to work. Yesterday, he had a sore throat and runny nose, he thought it was allergies from playing with some kittens his young nephews brought home from day care. This morning, he awoke with severe vertigo. He is nauseous but has not vomited. He is struggling to walk but can ambulate with assistance. He has noticed a soft ringing in his left ear since he woke up. He has no difficulty with speaking, no weakness, no sensory loss or facial droop, no limb dysmetria. No headache, his eyes move around but he can fixate on items when he chooses to.
Physical Exam: Visual exam shows horizontal nystagmus with the slow eye movement to the left and the rapid eye movement to the right. With instruction, the patient can fixate for the 6 cardinal positions and has intact convergence, no papilledema. When patient is instructed to fixate vision on the examiner’s eyes and the patient’s head is turned to the side, his eyes do not stay fixed on the examiner and make a corrective saccade back to the examiners nose (Head thrust test is positive => peripheral nervous system localization). Weber test shows sound louder in the right ear and gross hearing test shows inability to hear rubbing fingers held at 4 inches in the left ear. Rinne test shows decreased hearing to bone and air conduction in the left ear relative to the right ear. Romberg is positive with swaying to the left. Gait is ataxic, with the patient falling left repeatedly. Dix-Hallpike is negative. No problems with hand or foot coordination. No sensory loss in any dermatome or problems with proprioception, no muscle weakness.
Tests:
– MRI shows no structural abnormalities
– Hearing evaluation reveals a mild sensory-neuronal loss in the left ear. No deficit on the right side.