DOORWAY INFORMATION
Opening Scenario
Edward Albright, a 53-year-old male, comes to the ED complaining of dizziness.
Vital Signs
BP: 135/90 mm Hg Temp: 98.0°F (36.7°C)
RR: 16/minute HR: 76/minute, regular
Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
Checklist/SP Sheet
Patient Description
Patient is a 53 yo M, married with 3 children.
Notes for the SP
■ Ask the examinee to speak loudly. Pretend that you have difficulty hearing in your left ear and that you hear better when the examinee moves closer to your right ear.
■ Refuse to walk if the examinee asks you to. Pretend that you are afraid of falling down. Walk only if the examinee explains why he/she would like to see your gait.
Challenging Questions to Ask
“I am really scared about my hearing, doctor. Do you think this will be permanent? ”
Sample Examinee Response
“I understand your concern, Mr. Albright. A variety of permanent and nonpermanent conditions can cause your symptoms, but before I can confidently answer your question, I would like to do a few more tests to better understand why you have been dizzy and why your hearing is affected. After that, we can discuss possible reasons for your hearing problems.”
Examinee Checklist
Building the Doctor-Patient Relationship Entrance
□ Examinee knocked on the door before entering.
□ Examinee introduced self by name.
□ Examinee identified his/her role or position.
□ Examinee correctly used patient’s name.
□ Examinee made eye contact with the SP.
Reflective Listening
□ Examinee asked an open-ended question and actively listened to the response.
□ Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
□ Examinee summarized the SP’s concerns, often using the SP’s own words.
Information Gathering
□ Examinee elicited data efficiently and accurately.
Connecting with the Patient
□ Examinee recognized the SP’s emotions and responded with PEARLS.
Physical Examination
□ Examinee washed his/her hands.
□ Examinee asked permission to start the exam.
□ Examinee used respectful draping.
□ Examinee did not repeat painful maneuvers.
Closure
□ Examinee discussed initial diagnostic impressions.
□ Examinee discussed initial management plans:
□ Follow-up tests.
□ Examinee asked if the SP had any other questions or concerns.
Sample Closure
Mr. Albright, the dizziness you are experiencing may be due to a problem in your ears or brain, or it may result from low blood pressure. We will have to run some tests to pinpoint the source of your symptoms. These may include blood tests, a hearing evaluation, and an MRI that will provide detailed images of your brain. Until we find the cause of your problem, you should be careful when you stand up quickly or walk unaccompanied, and you should use hand railings whenever possible. Do you have any questions for me?
History
HPI: 53 yo M c/o intermittent dizziness x 2 days.
■ Sensation of room spinning around him.
■ Occurs during day when getting up or lying down.
■ Episodes last 20-30 minutes and are progressively getting worse.
■ Left-sided hearing loss since yesterday.
■ Nausea and vomiting.
■ Watery, nonbloody diarrhea x 3 days that has since resolved.
■ No tinnitus, fullness in ear, ear discharge, headache, or head trauma.
■ No recent URI.
ROS: Negative except as above.
Allergies: NKDA.
Medications: Furosemide, captopril.
PMH: Hypertension, diagnosed 7 years ago.
PSH: Appendectomy.
SH: No smoking, 2-3 beers/week, no illicit drugs.
FH: Noncontributory.
Physical Examination
Patient is in no acute distress.
VS: WNL, no orthostatic changes.
HEENT: NC/AT, PERRLA, EOMI without nystagmus, no papilledema, no cerumen, TMs normal, mouth and oropharynx normal.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Neuro: Cranial nerves: 2-12 grossly intact except for decreased hearing acuity in the left ear.
Rinne (air conduction > bone conduction on the left), Weber no lateralization,
tilt test. Motor: Strength 5/5 throughout. DTRs: 2+ intact, symmetric,
Babinski bilaterally. Cerebellar:
Romberg, finger to nose normal. Gait: Normal.
Differential Diagnosis
CASE DISCUSSION
Patient Note Differential Diagnoses
Vertigo signals vestibular disease, whereas lightheadedness and dysequilibrium are usually nonvestibular in origin. A central vestibular system lesion (eg, vertebrobasilar insufficiency, brain stem and cerebellar tumors, MS) is unlikely in this patient given the presence of hearing loss and an otherwise normal neurologic exam. Vertigo syndromes due to peripheral lesions are discussed below. These cases are often accompanied by nausea and vomiting, and vertigo may be so severe that the patient is unable to walk or stand.
■ Ménière's disease: This classically presents with episodic vertigo (usually lasting 1-8 hours) and low- frequency hearing loss as well as with features not seen in this case, such as tinnitus and a sensation of aural fullness. Symptoms result from distention of the endolymphatic compartment of the inner ear. Syphilis and head trauma are two known causes.
■ Benign paroxysmal positional vertigo (BPPV): This describes transient vertigo following changes in head position, but it is not associated with hearing loss.
■ Orthostatic hypotension due to dehydration: Risk factors for dehydration in this case include diarrhea and loop diuretic use. However, the patient does not complain of lightheadedness and is not objectively orthostatic.
Additional Differential Diagnoses
■ Labyrinthitis: This frequently follows a viral infection (usually URI) and is accompanied by hearing loss and tinnitus, but vertigo is usually continuous and lasts several days to a week.
■ Perilymphatic fistula: This is a rare cause of vertigo and sensorineural hearing loss that usually results from head trauma or extensive barotrauma. Episodes of vertigo are fleeting, generally lasting seconds.
■ Acoustic neuroma: Acoustic neuroma more commonly causes continuous dysequilibrium rather than episodic vertigo. As noted above, central lesions are unlikely in patients with vertigo, hearing loss, and an otherwise normal neurologic exam. However, an intracranial mass lesion must be ruled out in any patient with unilateral hearing loss.
Diagnostic Workup
■ Dix-Hallpike maneuver: Used to diagnose BPPV (look for nystagmus and reproduction of vertigo).
■ Audiometry: Used to assess hearing function.
■ MRI—brain: Required for the evaluation of central vestibular lesions.
■ VDRL/RPR: To rule out syphilis, which can cause Ménière’s disease.
■ Brain stem auditory evoked potentials: Used to help diagnose central vestibular disease.
■ Electronystagmography: Used to document characteristics of nystagmus that may differentiate central from peripheral vestibular system lesions.