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 45-year-old woman with dizziness.
HPI: Her symptoms started earlier today and she has been unable to stand since they began. She describes the sensation as the room spinning and not lightheadedness. She has no changes in vision and has not lost consciousness nor felt like she may. She has been nauseous since the onset and vomited twice. She regularly has vertigo symptoms secondary to vertiginous migraines; however this episode was not relieved by Sumatriptan and sleep, which is the effective strategy for previous experiences. The patient has noticed decreased hearing in her right ear over the last few months, but she states it always gets better after a few hours. She noticed a fullness of the ear and tinnitus yesterday evening and then the vertigo began a few hours later. She tried taking Sumatriptan and going to sleep, but she awoke with the same symptoms. She feels like her heart is beating out of her chest and she has increased anxiety.
PMH: Panic attacks treated with SSRI’s, vestibular migraines treated with Sumatriptan and sleep
Physical Exam: Patient is lying flat and is gripping the sides of the exam table. When she walked into the office, her husband had to hold her up to prevent her from falling over.
PE:
Vital signs are within normal limits, heart rate is at 95 BPM.
HEENT shows non-erythematous external canals and a transparent TM with appropriate mobility. Eye exam shows horizontal nystagmus with the fast beat towards the right and does not change with gaze. The patient can suppress the nystagmus by focusing on an object. Dix-Hallpike did not change the nystagmus. Rinne shows decreased bone and air conduction on the right ear and Weber localizes to the left.
Respiratory exam is clear to auscultation and percussion.
Muscukoskeletal/neurologic exam showed no weakness, parathesias or gross defect. Balance was such an issue that gait was deemed unsafe to observe.
Tests:
- Audiogram revealed decreased low frequency hearing on the right ear and normal hearing on the left ear
- ABG showed pH 7.35, pCO2 45mmHg, HCO3 24, and pO2 90mmHg
- CBC and CMP are within normal limits
- EKG – See below
