NeuroMed Discharge Summary

Patient: Ms. Smith, 68, Female, referred for recurrent dizzy spells. Problem List: # Vertigo, benign paroxysmal positional # Hypertension, essential # Osteoarthritis, knee Background: * Ms. Smith presented with a 3-month history of recurrent, sudden-onset dizzy spells, often triggered by head movements. These episodes typically last less than 30 seconds and are associated with a spinning sensation. No associated hearing loss, tinnitus, or focal neurological deficits. * Past medical history includes hypertension well-controlled with medication, and osteoarthritis of the left knee managed conservatively. * No significant family history of neurological conditions. On Examination: * Mental Status: Alert and oriented to person, place, and time. Speech clear, cognition intact. * Cranial Nerves: Pupils equal, round, and reactive to light. Extraocular movements full. Facial sensation and movement symmetrical. Hearing grossly intact. Gag reflex present. * Motor Exam: Normal tone and power (5/5) throughout. No fasciculations or tremors. * Sensory Exam: Intact to light touch, pinprick, vibration, and proprioception in all four limbs. * Reflexes: Biceps, triceps, brachioradialis, patellar, and ankle reflexes 2+ bilaterally and symmetrical. Plantar responses flexor bilaterally. * Cerebellar Exam: Finger-to-nose and heel-to-shin movements smooth and accurate. Romberg negative. Gait steady. Dix-Hallpike maneuver provoked transient rotational nystagmus and vertigo when head was turned to the right with the ear down. Investigation Findings: * Blood Tests: - Complete Blood Count: WNL - Electrolytes: WNL - Thyroid Function Tests: WNL * Imaging: - MRI Brain (15/10/2024): No acute infarct, haemorrhage, or mass lesion. Age-related white matter changes noted. Conclusion: * Differential Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV), Vestibular Migraine, Meniere's Disease, Orthostatic Hypotension. * Management Plan: Diagnosis of right-sided posterior canal BPPV confirmed by Dix-Hallpike. Epley maneuver performed in clinic with good resolution of symptoms. Patient educated on BPPV and home exercises. * Counselling Provided: Discussed the nature of BPPV, its benign course, and likelihood of recurrence. Emphasised avoiding sudden head movements and maintaining good hydration. Provided instructions for home Epley maneuver if symptoms recur. * Follow-up: Advised to return if symptoms persist or worsen, or if new neurological symptoms develop. Discharge Plan: * Medications: - Continue Amlodipine 5mg OD for hypertension. - No new neurological medications prescribed. * Lifestyle Modifications: - Avoid sudden head movements, especially looking up or lying flat quickly. - Maintain good hydration. - Ensure adequate sleep. * Home Exercises: - Perform home Epley maneuvers if BPPV symptoms return, as demonstrated. * Follow-up: - Review with GP in 2 weeks if symptoms have not fully resolved. * Investigations: - No further investigations planned at this time.