Case 40: Dizziness

Opening scenario

Fred Potter, a 25-year-old male, comes to the doctor’s office because of dizziness.

Vital signs

• Temperature: 99.5°F (37.5°C)
• Blood pressure: 120/70 mm Hg
• Heart rate: 65/min
• Respirations: 18/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act like you cannot hear on the right side. If the examinee does not speak loud enough, ask for clarification or pretend not to hear her/his question.
• When the examinee looks at your right ear, show him/her this image and pretend that your right ear hurts when the examinee touches it.
• When the examinee places the tuning fork on the top of your head, say that you can hear the tone louder on the left side.
• When the examinee places the tuning fork on the bone behind your ear until you can no longer hear it and then places it next to your ear, say that you can hear the tone again.
• When the examinee asks you to stand with both feet together, raise your arms, and close your eyes, act as if you are tipping over sideways.
• You are not aware of the meanings of medical terms (e.g., audiogram) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Interrupt the examinee while she/he is asking you about your health and say: “Why do you need to know all this? I think coming here was a mistake. I should leave. I need to get home to my cats – somebody has to feed them.”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I feel really dizzy.
  • Describe dizziness
  • I feel like the room is spinning around me.
• Onset
• It started really suddenly last night.
• Constant/intermittent
• It is there all the time.
• Precipitating events
• I do not remember anything out of the ordinary.
• Progression
• I think it is staying about the same.
• Previous episodes
• No.
• Alleviating factors
• Nothing. It is horrible.
• Aggravating factors
• No.
• Associated symptoms
• I feel nauseous because I am so dizzy. I have not had to vomit though.

Review of systems specific to vertigo

• Trauma
• No.
• Headache
• No.
• Fever/chills
• I have not taken my temperature, but I feel like I may have a bit of a fever.
• Rash/skin changes
• I have not seen anything.
• Cough
• I had a little bit of a cold last week and had a cough then, but I think it is gone now.
• Recent infections
• Only the cold last week.
• Tinnitus
• Yes, in my right ear.
• Ear fullness
• Yes, also in my right ear.
• Hearing loss
• Yes. I think it is mostly my right ear, too.
• Vision changes
• No.
• Numbness/weakness/tingling
• No.
• Pruritus
• Yes, my right ear has been itching for the past few days. I thought it was just wax so I cleaned it out, but it did not help.

Past medical history, family history, and social history

• Past medical history
• I hurt my knee playing football last year. Ruptured my ACL.
  • Chicken pox in the past
  • Yes, I am pretty sure I had chicken pox as a child.
• Allergies
• None.
• Medications
• I take some aspirin for my knee sometimes, it still hurts when I run or play football.
• Hospitalizations
• I had surgery for my knee last year.
• Ill contacts
• None.
• Past surgical history
• Only the knee.
• Family history
• My older brother has neurofibromatosis.
• Work
• I manage a car wash.
• Home
• I live by myself.
• Alcohol
• Only on the weekends.
• Recreational drugs
• I usually smoke a joint when I get home from work to relax a little bit, I only do it at night, never during the day.
• Tobacco
• Yes. I smoke about half a pack every day. I think I was 14 when I started.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
  • Inspection of the ears
    • Show the examinee this image
  • Palpation of the ears
    • Right ear tender to palpation
  • Otoscopy
  • Rinne test and Weber test
    • Rinne: positive bilaterally, Weber: lateralization to the left ear
  • Dix-Hallpike test
• Neurologic examination
  • Focused examination of the cranial nerves
  • Focused examination of hearing
    • Decreased hearing on the right
  • Focused examination of passive and active motion
  • Focused examination of sensation
  • Focused examination of deep tendon reflexes
  • Focused examination of gait
  • Rapid alternating movement test
  • Finger-to-nose test
  • Romberg test
    • Positive

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on recreational drugs.
• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Potter, I understand that you are worried about your cats, but you made the right decision today by coming in to see me. It is important that I ask all these questions in order to better understand what is causing your symptoms so that we can treat you correctly. I would like to ask you just a few more questions and examine you before you go. I would be happy to call someone for you who could take care of your cats, such as a friend or relative. However, as your doctor, it is my job to keep you in your best possible health, and to do that I need to rule out any conditions that could permanently affect your hearing before sending you home. How would you feel about that?”

Patient note

Differential diagnoses

1. Herpes zoster oticus (Ramsay Hunt syndrome): The URI of this patient a week prior to his current symptoms most likely weakened his immune system enough to allow reactivation of the varicella zoster virus in the vestibulocochlear nerve, causing herpes zoster oticus. The features that make this diagnosis most likely are vertigo, hearing loss, tenderness and pruritus of the pinna, low-grade fever, and most importantly the characteristic herpetic lesions (i.e., grouped vesicles on an erythematous base).
2. Ménière disease: Vertigo, tinnitus, and hearing loss form the triad of Ménière disease, a disease that usually affects patients older than Mr. Potter (40–60 years) episodically. Although cochlear symptoms are a feature of Ménière disease, and patients typically present with a positive Romberg test, the herpetic lesions on the pinna of this patient make herpes zoster oticus more likely.
3. Vestibular neuritis: Severe vertigo and nausea are symptoms of vestibular neuritis, which is sometimes associated with upper respiratory infections. However, it is also associated with gait instability, which this patient does not have, and it does not present with cochlear symptoms (e.g., hearing loss, tinnitus), which are seen here, making it the least likely of the three main differential diagnoses.

Diagnostic studies

• Tone audiometry: to rule out sensorineural hearing loss in herpes zoster oticus. Low-frequency hearing loss would be seen in Ménière disease.
• Brain stem auditory evoked potentials: to rule out a central nervous system lesion

Other differential diagnoses to consider

• Benign paroxysmal positional vertigo
• Vestibular migraine
• Acoustic neuroma
• See also differential diagnoses for vertigo.