Collin Grimes Patient Write Up June 14, 2015

History:
Chief Complaint/HPI
A 44 year-old Caucasian female was seen in the clinic with a chief
complaint of dizziness. Patient denies syncope or trauma. The symptoms
started 3 days ago and have progressively increased. Patient states she has
noticed a worsening of symptoms when she moves her head forward and to
the left. States the dizziness is intermittent. Has taken Dramamine for
symptomatic relief, however states it makes her lethargic.
Past Medical History/Surgical History
Patient has a medical history of hypertension, hyperlipidemia, and
vitamin B12 deficiency.
Patient has no surgical history to date.
Social History/Family History
Patient denied recreational, or street drug use; admits alcohol use 2-3 times
per year. Patient reported a 10 pack year smoking history, but has not
smoked in over 10 years. Patient lives at home in Batesville with her
husband. Patient could not recollect any significant family medical history
other than her Aunt has had similar symptoms in the past and was seen by
an ENT. States she had rocks in her ears.
Current Medications
Lisinopril, Pravastatin
Allergies:
No Known Drug Allergies
Review of Systems:
Constitutional
- Patient denied fever, fatigue
- Patient admitted headaches that come with the vertigo
- Patient reported intermittent dizziness that is associated with head
movements
Eyes
- Patient denied eye pain, redness, and excessive watering
- Patient uses contacts for vision
- Patient denied purulent discharge
ENT
- Patient denied epistaxis or sore throat
- Patient denied ear fullness or pain
- Patient denied sinus pressure or sinus drainage
Cardiovascular
- Patient denied chest pain, or syncope

Patient denied palpitations. No edema.

GI
- Patient denied vomiting
- Patient admitted nausea with the vertigo at times
- Patient denied constipation or diarrhea
- Patient denied abdominal tenderness
GU
- Patient denied painful urination
- Patient denied hematuria
- Patient denied vaginal discharge
Musculoskeletal
- Patient denied back or neck pain
- Patient denied arthralgias
Skin
- Patient denied cellulitis, rash
Neurologic
- Patient denied focal weakness, paralysis
- Patient admitted headache concurrent with vertigo
- Patient admitted dizziness
Psychiatric
- Patient denied any depression, mental status changes
Physical Exam
Constitutional
- Vital Signs:
o Pulse: 72
o Resp: 16
o Temp 98.2 (Oral)
o O2 Sat: 99% on RA
o Blood Pressure: 126/80
- Pain: 0 (1-10 Scale)
Head
- Head exam included findings of head atraumatic, normocephalic
Eyes
- Eyelids normal to inspection, pupils equally round and reactive to light,
extraocular muscles intact, patient wearing contact lenses at the time
of the exam
ENT
- Nose exam normal, pharynx exam normal
Neck
- Neck exam included findings of normal range of motion, trachea
midline
Lymph
- No lymphadenopathy, enlargement, or masses
Respiratory Chest

Respiratory exam included findings of normal breath sounds; breath

sounds clear
Cardiovascular
- Heart Rate Normal (72); Heart sounds normal; No bruits or rubs on
auscultation of heart or carotid arteries
Abdomen
- Abdominal exam included findings of soft with no scarring noted. No
striations.
- No tenderness noted upon palpation
- Liver and Spleen within normal limits
- No pulsatile masses or abdominal bruits
Upper Extremity
- Upper extremity exam included findings of inspection normal; range of
motion normal
- Lower extremity exam included findings of inspection normal; range of
motion normal
Genitalia
- Genital Exam Deferred
Neuro
- Neuro exam findings include patient oriented to person, place, and
time; speech normal
Skin
- Skin exam included findings of skin warm, dry, and normal in color
- No jaundice of the skin noted
Psychiatric
- Psychiatric exam included findings of patient oriented to person, place,
and time; normal affect
Lab Findings
Epley Maneuvers positive with nystagmus noted on maneuvers bilaterally.
Assessment:
1) Benign Paroxysmal Positional Vertigo
Plan:
1) Start Meclizine 25mg PO PRN for Vertigo
2) Follow up with Balance Clinic in Batesville for further workup and
treatment
Follow up
1) Patient referred to the Balance Clinic; told to follow up in 1 month or as
needed for worsening of symptoms.

Literature Search:

http://emedicine.medscape.com/article/884261-overview
http://www.nlm.nih.gov/medlineplus/ency/article/001420.htm