REASON FOR CONSULT: Vertigo.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who is being seen in consultation for second opinion of vertigo. The patient has been evaluated here in the past. There is a balance evaluation that was completed previously, which demonstrated some gait related issues with platform testing but no other obvious vestibular dysfunction. According to the patient, she recently underwent a similar evaluation, which again did not document any vestibular dysfunction.
Her symptoms are somewhat vague, but she refers to her symptoms as dizziness. This primarily, however, is a feeling of unsteadiness with a sudden onset of a tendency to fall or become unsteady. This generally happens, if she is bending or moving her head and neck. She may have had some episodes of isolated vertigo with true spinning sensation in the distant past, which were related to positional changes while rolling in bed, but this is not her current complaint.
She did have significant head trauma in the past requiring evacuation of cerebral hematomas. At that time, she may have also had significant trauma to her neck; although, no surgery was performed of her neck. These episodes can occur in waves. She has not found any specific triggers.
The patient denies any visual changes such as loss of vision or blurred vision or double vision, speech or language difficulties; although, at baseline, she has dysphonia which was also evaluated in the past here with no specific neurologic or otolaryngological explanation.
She has, at baseline, some left lower facial droop but that is not acute. She has not experienced any tinnitus or hearing loss or numbness or tingling or focal weakness, bowel or bladder changes. She denies any fevers or chills or chest pains or palpitations.
PAST MEDICAL HISTORY: As detailed above with questionable seizure disorder in the past related to head trauma but no seizures recently. She also has adult attention deficit disorder and hypertension.
CURRENT MEDICATIONS: Omeprazole, lisinopril, carbamazepine, acyclovir for a nasal lesion, dextroamphetamine ER, and cetirizine.
ALLERGIES: NKDA.
SOCIAL HISTORY: She is divorced. She does not smoke and occasionally has a glass of wine.
FAMILY HISTORY: Negative for neurologic disease. Her father died of unknown cancer at the age of 46 and her mother had colon cancer.
PHYSICAL EXAMINATION: Blood pressure is 156/94 with pulse of 72 and regular, respiratory rate 12, and pain scale of 0. She is sitting comfortably in a chair, well groomed with normal affect. She has some dysphonia but that is her baseline. She is alert and oriented with no evidence of dysarthria or aphasia. There is no right-left confusion or finger agnosia. Concentration is intact and recall is normal.
Cranial nerve examination reveals normal fundi with sharp disk margins. Pupils are symmetric and reactive. Extraocular muscle movements are without nystagmus. Visual fields are full. There is a mild left lower facial droop, which is old with no facial weakness. Tongue is midline. Palate elevates symmetrically bilaterally. Hearing to bedside testing is normal. Shoulder shrug is normal.
Motor examination reveals no tremors or myoclonus or focal weakness. Cerebellar testing, finger-to-nose is normal. Her gait is normal, but when we asked her to move her head and neck side to side while walking, she quickly became unsteady but was able to correct also relatively quickly.
Sensory examination is unremarkable. Deep tendon reflexes are 2+ throughout, and toes are downgoing. There is no sensory level.
DIAGNOSTIC DATA: MRI of the brain as well as an MRI of the neck was reviewed. There is evidence of old injury with encephalomalacia in the left temporal and left frontal areas but no other abnormalities, especially none in the brain stem. Cervical MRI demonstrated moderate amount of stenosis in the middle of the cervical spine with some spurs. The spinal cord itself appears to be normal.
ASSESSMENT AND PLAN: The patient may have cervicogenic disequilibrium. We believe that neck exercises would be the most reasonable approach to pursue. We do not believe additional testing will be helpful. This may continue to be a chronic problem for her, however, despite our best efforts. There is no evidence at this time that this is related to vestibular dysfunction. We educated the patient about the condition and told her we will be happy to see her again in the future on as-needed basis.
