Presenting Complaints

The patient, a 36-year-old female, presents with a chief complaint of dizziness.

History of Presenting Complaint

The patient reports experiencing episodes of sudden-onset dizziness and vertigo for the past 2 weeks. She describes the sensation as a spinning or whirling feeling, often triggered by changes in head position, such as when rolling over in bed or looking up. The episodes typically last for 30 seconds to a minute and are accompanied by nausea. She denies any hearing loss, tinnitus, or ear pain. The patient states that the dizziness has been interfering with her daily activities and causing her to feel unsteady on her feet.

Significant Positives & Negatives For Differentials

Benign Paroxysmal Positional Vertigo (BPPV)

Positives:

• Sudden-onset, brief episodes of vertigo triggered by changes in head position
• Absence of other neurological symptoms or hearing loss
• Consistent with the patient's presentation

Negatives:

• Potential for recurrent episodes
• Possibility of underlying condition causing BPPV

Ménière's Disease

Positives:

• Family history of Ménière's disease
• Episodes of vertigo, hearing loss, and tinnitus

Negatives:

• Hearing loss and tinnitus not reported by the patient
• Vertigo episodes may be more prolonged than in BPPV

Vestibular Migraine

Positives:

• Patient's history of migraines
• Vertigo episodes can be associated with migraines

Negatives:

• Lack of other migraine symptoms (e.g., headache, visual aura)
• Vertigo episodes may not be as closely linked to head position changes

Stroke or Transient Ischemic Attack (TIA)

Positives:

• Sudden onset of dizziness
• Potential for other neurological symptoms

Negatives:

• Patient's age and lack of other neurological symptoms make this less likely
• Vertigo episodes are typically more prolonged in stroke/TIA compared to BPPV

Past Medical History

The patient has a history of migraines, which she has experienced since her early 20s. She reports that the migraines occur approximately once a month and are usually accompanied by visual aura. She takes ibuprofen as needed for migraine relief.

Drug/Medication History

The patient takes ibuprofen as needed for her migraines. She does not take any other regular medications.

Social History

The patient is married and works as an accountant. She denies any history of alcohol or tobacco use.

Family History

The patient's mother has a history of Ménière's disease, a condition characterized by episodes of vertigo, hearing loss, and tinnitus.

Systems Review

The patient denies any recent changes in hearing, vision, or balance. She reports no history of head trauma or recent viral illnesses. She has not experienced any significant weight loss or changes in appetite.

Ideas, Concerns & Expectations

The patient is concerned that the dizziness may be a sign of a more serious underlying condition. She is hoping the doctor can provide a diagnosis and effective treatment to alleviate her symptoms.

Case Presentation

Based on the patient's history and presentation, the most likely diagnosis is benign paroxysmal positional vertigo (BPPV). The patient's description of sudden-onset, brief episodes of vertigo triggered by changes in head position, along with the absence of other neurological symptoms or hearing loss, are highly suggestive of BPPV.

The differential diagnosis should also include Ménière's disease, given the patient's family history, and vestibular migraine, considering the patient's history of migraines. However, the lack of reported hearing loss, tinnitus, and the relatively short duration of the vertigo episodes make these diagnoses less likely.

To confirm the diagnosis of BPPV and rule out other potential causes, the student should recommend appropriate diagnostic tests, such as a Dix-Hallpike maneuver and audiometric evaluation. Treatment for BPPV typically involves repositioning maneuvers, such as the Epley or Semont maneuver, to resolve the displaced otoconia in the inner ear.