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 54 year old woman who presents to the ED with acute dizziness and weakness.
HPI: Two days ago, the patient was watching TV in the afternoon and became dizzy. She described the sensation as the room spinning and she felt like she was going to topple out of her chair to the left. After an hour or so, the sensation went away and she thought nothing of it. This afternoon after lunch, her symptoms returned. She was walking out to get the mail and had a sudden onset of vertigo and kept falling to the left. She struggled to get back up and required assistance from her husband to get into the house. She became nauseous and vomited twice. At the same time, she noticed difficulty with left hand movements and was unable to lift a glass to her mouth to drink water with the affected hand. She tried taking a nap to let the symptoms subside but woke up after 2 hours with the same symptoms. She also noticed some difficulty speaking. At this time, her husband brought her to a prompt care and she was swiftly rerouted to the local emergency room. She has now had symptoms for 3 hours.
PMH: HTN diagnosed at age 26, didn’t start actively controlling until 52. Diabetes mellitus diagnosed at 45 years of age and treated with Metformin. Dyslipidemia diagnosed at 45 years of age, not treated because Statins give her “muscle aches.” History of stable angina treated with Nitroglycerin, and claudication of the left leg. 45 pack year history of smoking and she currently drinks 2 Moscow Mules every night to help her sleep.
Physical Exam –
VS: Height 64” (162cm), Weight 138lbs (62.6kg), BMI 23.7 HR 95, BP 100/65, RR 18, Temp 98.6, O2 saturation 100% on room air
The patient is laying on the exam table and is gripping the sides. She is unable to sit up because she will topple over, she is also unable to walk unaided because she falls (always to the left). With the help of her husband, her gait is observed and it is wide based and uncoordinated. She is able to perform the finger-nose test with her left hand as she is not weak but is dysmetric (coarse tremor that worsens as her finger approaches the target prevents her), no problems with right hand. Right heel-shin test shows no abnormalities, but left heel-shin test shows lack of coordination and cannot be completed. Eye exam shows nystagmus which is predominantly vertical, but changes directions while testing for extraocular movements; it worsens when fixating on an object. When testing the cranial nerves, her left eyelid is drooping, she has weakness in turning her head to the right and when sticking out her tongue (it deviates to the left). All other cranial nerves tested were appropriate. No other muscle weakness or sensory deficits were observed.
- HgA1c was 7.3
- Fasting Lipid Panel shows Cholesterol 254mg/dl, Triglycerides of 326mg/dl and HDL 24 mg/dl, LDL was 94 mg/dl
- MRI – see below