Case #65 "Off the
Merry-Go-Round"
by Charlene Babcock Irvin, MD, FACEP
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A 79 y/o female is brought in by her
daughter who notes her mom feels very dizzy.
Most of the history is from the daughter as
the patient is very hard of hearing, a very
poor historian, and doesn’t speak fluent
English. The patient mostly gives one-word
answers (yes/ no), and only when asked
several times loudly. She does state: “I
want off the merry-go-round. Make it stop.”
She was fine yesterday, but today woke up
with severe dizziness. The dizziness is like
a sensation of spinning (best you can tell
from her and her daughter) and not like she
might faint. She has vomited multiple times.
Any movement makes it worse, and even when
not moving she is still very dizzy.
ROS: No fevers, headache, numbness or
tingling. No focal weakness (daughter notes
she has generalized weakness (‘she is weak
as a kitten from all the vomiting!’).
Yesterday she felt fine, ate a normal
dinner. Vomiting was initially partially
digested food, but then just bile and dry
heaves. No hemetemesis or coffee-ground
emesis. No chest pain. She does complain of
pain in her stomach from vomiting. No
diarrhea. No back pain. No dysuria,
frequency, urgency. Last BM was normal
yesterday. No rashes. No new hearing loss
(patient is very hard of hearing at
baseline), no tinnitus or fullness in the
ears.
PMH: NIDDM, Hypertension.
Meds: Glucophage, Lopressor
Allergies: None
PE: Thin frail female, sitting upright on
the cot (the back of the cot supporting her
back), with an emesis basin in her hands.
She has her eyes closed, and only opens them
when she has to. She is sitting very still,
and skin is clammy. She resists any movement
and just wants to sit very still.
VS: BP 160/90, HR 105, RR=24 (shallow),
Temp: afeb Sat 95% RA
HEENT: PERRL. Unable to check for nystagmus
as she wont keep her eyes open very long.
Neck supple. Mouth unremarkable. No carotid
bruits.
HEART: RR slightly tachycardic. NO murmurs
LUNGS: =BS, normal
ABD. Soft scaphoid. No AAA palpable, mild
tenderness to epigastric area. No guarding
or rigidity. BS decreased.
EXT: No cyanosis, no rashes
NEURO: Motor 5/5 throughout. No sensory
abnormality. Reflexes are diminished
throughout, but present. Down going babinski.
CN Difficult to access. No facial asymmetry,
and eye motor exam difficult as she wont
follow commands with her eyes. She is unable
to do finger to nose because she doesn’t
want to keep her eyes open that long. If you
force her, she begins to have dry heaves.
Gait testing is not possible. Mental status
per daughter is normal. She knows the year
and date.
You attempt the Dix-Hallpike maneuver, but
before you can lay her flat, she begins to
have dry heaves from any movement.
1. What should you order?
2. What is the Dix-Hallpike maneuver?
3. Is this central or peripheral vertigo?
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