Presenting History:
- The patient reports the sudden onset of vertigo approximately 2 hours prior to presentation.
- The patient denies any chest pain, shortness of breath, palpitations, dizziness on standing or syncope.
- The patient denies any motor, sensory, visual, coordination, or speech-related symptoms.
- The patient denies any head, neck, or facial pain.
- The patient reports mild tinnitus in the left ear.
- The patient denies any fever, back pain, abdominal pain, urinary complaints or generalised malaise.
- The patient denies any recent trauma, head injury, or chiropractic manipulation involving the neck.
- The patient describes the vertigo as a spinning sensation, lasting for several minutes at a time, triggered by head movements, and associated with mild nausea.
Past Medical History:
- The patient has a history of hypertension, well-controlled with medication.
- Medications: Lisinopril 10mg daily.
- Allergies: No known allergies.
Vital Signs:
- Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 37.0°C.
Neurological & Vestibular Examination:
- Cranial nerves II-XII intact. Normal limb tone, reflexes 2+ and symmetrical. Coordinated finger-to-nose and heel-to-shin testing. Gait normal.
- HINTS exam: Head impulse test negative, downbeat nystagmus present, no skew deviation.
Balance Assessment:
- Romberg test: slight sway. Tandem gait: unsteady. Dix-Hallpike test: positive for left ear.
- Audiometry and VNG performed.
- Findings are suggestive of peripheral vestibular dysfunction, likely left-sided.
- Patient demonstrated unsteadiness during tandem gait.
Red Flag Screening:
- No red flags identified.
Clinical Impression:
- Benign paroxysmal positional vertigo (BPPV), left ear.
Management Plan:
- Epley maneuver performed, with resolution of vertigo. Patient instructed on home exercises.
- Patient advised to return if symptoms worsen or do not improve within 2 weeks.
