HPI
A 46-year-old man was helping friends lift a refrigerator up the stairs. He noted the sudden onset of a spinning sensation and some ringing in his right ear. These symptoms lasted continuously for several hours and his friends took him to the ER. The patient was brought to the ER where he complained of a mild bifrontal headache, blurred vision, and nausea.
PMH
Unremarkable
FH
Unremarkable
PE
- General Exam: Unremarkable
NEURO
- MS: Normal
- CN: Diplopia that was eliminated by covering each eye. The patient reported that images were both horizontally and vertically displaced ("skewed vision"). There was persistent nystagmus that increased with right gaze (fast component to the left). The patient’s sensation of movement and nausea did not reduce when he held perfectly still.
- Gait: Narrow based, but the patient felt as though he was falling backwards and to the right with his eyes closed.
The remainder of the neurological examination was unremarkable and by morning the patient had an unremarkable examination. The next day he felt fine and did not recall the event at all.
Study Questions:
- What are the important features about his history?
- What are the important features about his examination?
- What neurological system(s) is (are) affected?
- He was observed overnight in the ER and by morning his examination was normal and he felt fine. What this appropriate?
- What if any studies are needed and why?
- Sudden onset of dizziness is a very common ER complaint. How does one distinguish potentially serious problems from common vestibular dysfunction?
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