Patient Name: Jane Doe
Diagnosis: 

Date of Birth: XX/XX/1969 (54 years old)

vestibular evaluation

Date Seen: 8/2/2023
Referring Physician: Dr. Smith
Gender: Female

Subjective

Current Condition
Present Illness / Symptoms: Patient is a 54-year-old female that presents to the clinic with the sudden onset of rotational vertigo with N&V and unilateral hearing loss 1 week ago. She was checking the air in her motorcycle tires when she had the onset of tinnitus, dizziness, and nausea. She went into the house, thinking she might be overheated. She drank some water and took a nap. When she awoke, she had the onset of vertigo and nausea that eventually led to vomiting for 3 hours. She also had difficulty hearing out of her right ear and had tinnitus. She went back to bed because movement was worsening her symptoms. Due to the ongoing N&V, she went to urgent care, was diagnosed with vertigo, and was given an IV drip for dehydration and Phenergan for her N&V. She was recommended to see an ENT due to hearing loss. She didn’t take Phenergan for more than 1 day because it caused severe drowsiness. She was also prescribed meclizine which she took for a few days. The bad vertigo and her vomiting stopped by the next day. She continued to have some tinnitus and hearing loss and was scheduled to see an ENT, but could not make an appointment until 10 days from now. A friend had been seen in our clinic for “ear crystals” and recommended she make an appointment. During the visit today, she reports dizziness that she describes as feeling “off,” especially with head movements. She feels “ok” driving but does not like to move her head side-to-side which seems worse when she looks over her right shoulder to check behind her. She also reports intermittent spells of vertigo that appear positional in nature: it can be worse with lying down, especially flat and when drying her head upside down. She reports a history of hearing loss in her right ear over the last 5 years with recurrent vertigo and ipsilateral tinnitus that is persistent and is sometimes pulsatile. The tinnitus doesn’t bother her unless it’s “really quiet.” Her recent symptoms are much worse than her previous spells. The severity has improved since the onset but she has never had residual symptoms like this. She has tried self-treatments for “loose ear crystals,” but it hasn’t helped. She didn’t know which side to treat, so she just treated both. She tried the Somersault maneuver from YouTube, but it made her worse. She reports having 3 events of right Bell’s Palsy but it doesn’t last more than a week, and she has always fully recovered.

Review of Systems
PMHx: (+) right ear hearing loss for 5 years – cause unknown. 3 events of right Bell’s Palsy w/in last 3 years with a complete recovery. She had a hearing test and was recommended to have an MRI but she never followed up because it didn’t bother her, and her vertigo resolved. (+) seasonal allergies. Postmenopausal. PSHx: none. Social Hx: married 12 years. Works full-time as PT. Good family and friend support. Rides a motorcycle – wears a helmet. No history of head trauma. Non-smoker. Alcohol: social drinker. Denies use of illicit drugs. Exercises 5 days a week – weight training, swims, and walks – 30 minutes per session. Mental Health Hx: denies anxiety, depression, and suicidal ideation. Medications: no prescription; OTC flonase prn. NKDA

Objective

VNG

Examination      

Spontaneous Nystagmus (sitting)
Gaze-Evoked Nystagmus – horizontal
Gaze-Evoked Nystagmus – vertical
Smooth Pursuit
Saccades
Static Positional Testing
Dix-Hallpike Test - Right
Dix-Hallpike Test – Left
OPK – Fixed
Bithermal Caloric weakness

Findings

(+) left beating nystagmus w/o fixation only; 11 deg/sec
No clinically significant nystagmus noted in any gaze positions
No clinically significant nystagmus noted in any gaze positions
Normal gain, normal symmetry, good waveform morphology
Normal velocity, normal latency, and good waveform morphology
Subclinical LBN
(+) LBN; 6 deg/sec with nausea
(+) subclinical LBN
Normal gain, normal symmetry, good waveform morphology
33% right caloric weakness with 19% DP

VNG

Examination

Spontaneous Nystagmus (sitting)



Gaze-Evoked Nystagmus – horizontal


Gaze-Evoked Nystagmus – vertical



Smooth Pursuit



Saccades




Static Positional Testing

Dix-Hallpike Test - Right


Dix-Hallpike Test – Left

OPK – Fixed




Bithermal Caloric weakness

Findings

(+) left beating nystagmus w/o fixation only; 11 deg/sec

No clinically significant nystagmus noted in any gaze positions

No clinically significant nystagmus noted in any gaze positions

Normal gain, normal symmetry, good waveform morphology

Normal velocity, normal latency, and good waveform morphology

Subclinical LBN


(+) LBN; 6 deg/sec with nausea


(+) subclinical LBN


Normal gain, normal symmetry, good waveform morphology

33% right caloric weakness with 19% DP

Blocked out due to questions related to the case study quiz.

Blocked out due to quiz questions related to the Clinical Pearls Case Study Challenge.

Blocked out due to quiz questions related to the Clinical Pearls Case Study Challenge.

Blocked out due to quiz questions related to the Clinical Pearls Case Study Challenge.

Blocked out due to quiz questions related to the Clinical Pearls Case Study Challenge.

Blocked out due to quiz questions related to the Clinical Pearls Case Study Challenge.

Blocked out due to quiz questions related to the Clinical Pearls Case Study Challenge.