DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Vertigo.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has a complicated medical history, including coronary artery disease and a stroke with hemorrhagic conversion. She states that she woke up this morning, was in her normal state of health. She walked into the bathroom. As she was about to sit down on the toilet, she stated that she felt like the room was spinning. The patient stated that her face got flushed and that this sensation lasted for approximately 5 minutes and then resolved spontaneously.
The patient denies any double vision. She denies any numbness. She denies any weakness. She denies any difficultly speaking. Once her symptoms resolved, the patient states they did not return. She denies any headache at this time. She denies any chest pain or shortness of breath while this event occurred. The patient states that she is concerned because she wants to know if her Coumadin is too much for her.
At the time of my evaluation, the patient does have a number of constitutional complaints, but she has not had any more episodes of vertigo, and she states that she has no acute complaints. Everything that she is complaining about at this time is chronic.
PAST MEDICAL HISTORY: Hypertension, coronary artery disease, CVA with a left-sided deficit.
MEDICATIONS: Benicar, Prilosec, Norvasc, metoprolol, vitamin D, Tylenol Extra Strength, Crestor, and Macrobid.
ALLERGIES: Multiple medication and food allergies, listed in the chart.
SOCIAL HISTORY: No tobacco, alcohol or drugs. She lives at home with her significant other.
REVIEW OF SYSTEMS:
The patient had an essentially pan-positive review of systems but were all remote complaints.
CONSTITUTIONAL: The patient states that she feels fatigued.
HEENT: The patient states that she has intermittent chronic headaches though she is not having one acutely.
CARDIOVASCULAR: The patient states that sometimes she does feel chest pain, though is not feeling any acutely.
Essentially, this was a pan-positive review of systems.
PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, nontoxic, alert and oriented x4. GCS 15.
VITAL SIGNS: Blood pressure 210/84, heart rate 52, respiratory rate 18, temperature 37.4, and saturation 99% on room air, which is normal.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact without any nystagmus. No diplopia in any fields.
NECK: Supple. Full range of motion. No bruits. No LAD. No JVD.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. No pulsatile masses.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No rashes, petechia or purpura.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Strength is 5/5 x4 extremities. Sensation is intact to light touch distally. Finger-to-nose, heel-to-shin is normal. Speech is normal. Gait is normal. There is no pronator drift.
PSYCHIATRIC: Normal affect, cooperative to the exam.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. She was admitted to the emergency room for observation. She was placed on to a cardiac monitor and continuous pulse oximetry. An EKG was done. It was reviewed. It showed a junctional rhythm with a ventricular rate of 54, but there were normal intervals. There was an abnormal axis, but there were no ST changes or T-wave inversions suggestive of acute ischemia, and compared to the previous EKGs, there were no acute changes.
The patient had a laboratory workup done; the results were interpreted. She had a CBC, which was completely within normal limits with a normal white blood cell count, normal hemoglobin, hematocrit, and platelets were 182. She had a set of cardiac enzymes that were negative. Complete metabolic panel was completely within normal limits. Coagulation studies; her INR was 1.9 which is consistent with her Coumadin use, and the urinalysis was negative.
She also had radiologic workup, including a head CT which was interpreted by the radiologist as having atrophy and chronic ischemic disease and old lacunar infarct, but no acute changes, and a chest x-ray was done that showed no acute pulmonary process. The patient was reevaluated after the completion of her workup in the emergency room. She had no change in her exam. She had no new symptoms, no return of vertigo, and was essentially at her baseline.
MEDICAL DECISION MAKING: The patient had 5 minutes of vertigo and flushing that occurred this morning when going to the bathroom. The patient does not state that it was a presyncopal event. She does state that it was a vertiginous event. We did consider that this could be a central cause of vertigo like a stroke or a cervical artery issue; however, the patient had no deficit at this time.
Although an MRI would be more specific, we do not feel that the patient has a concern for an ongoing central cause of vertigo. There certainly was no evidence of bleeding and the patient is already anticoagulated with therapeutic INR at this time. She had no bruits, no neck pain, and we do not feel this is a cervical artery problem either.
As far as other causes of vertigo, certainly peripheral causes were considered, including benign positional vertigo and labyrinthitis, vestibular neuritis or Meniere disease. All these are possible, but having only one single episode, we do not feel the patient needs any treatment, and unless these symptoms recur, does not need any further workup for this. We do not think that this was a transient ischemic event, again because of the negative neurologic signs and being already on Coumadin.
It is possible that this was an exacerbation of old stroke symptoms. Could have to do with the patient’s elevated blood pressure; however, the patient states she has not taken her blood pressure medication today. At this time, the patient is asymptomatic. Her workup in the emergency room was essentially negative for any acute issues, and we feel that she can safely be discharged. She already has followup this week with her cardiologist and her primary care doctor. The patient is to return to the emergency room for any new or worsening symptoms.
DISPOSITION: Home.
CONDITION: Stable and improved.
DIAGNOSIS: Vertigo, peripheral, resolved.
