Nervous System & Special Senses


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S25_F1.jpg"}},{"insert":"\n\n"},{"insert":"It has been a long and boring day. As the current patient walks out, you look at your nurse, Mrs. Garcia.\r\n\r\n\u0022Any more patients?\u0022, you ask.\n\n\u0022Yes, doctor! Mr. Vicari is the last patient for today. Shall I let him in?\u0022, she asks.\r\n\r\n\u0022Yes, please!\u0022, you reply.\r\n\r\nA few moments later, an elderly man walks in, accompanied by an elderly woman.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S25_F2.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Good afternoon! It\u0027s a pleasure to meet you, Mr. Vicari\u0022, you say.\r\n\r\n\u0022Nice to meet you! Please call me Tim, doctor!\u0022, he replies.\n\n\u0022How can I help you today, Tim?\u0022, you ask.\r\n\r\n\u0022Well doctor, I\u0027ve been feeling dizzy every now and then, and it really bothers me\u0022, he says.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S25_F3.jpg"}},{"insert":"\n\n"},{"insert":"While talking, you start taking notes:\r\n\r\nTim is 71 years old. His chief complaint is vertigo that occurs when he gets out of bed in the morning, and whenever he stands up from a seated position. Each episode lasts for a couple of minutes. This started around two weeks back, and has occurred every day since.\n\nHe had a couple of similar but isolated episodes around an year or so ago, but didn\u0027t seek medical attention at that time.\r\n\r\nTim\u0027s medical history is significant for mild essential hypertension that is well controlled on losartan 50 mg daily, and mild dyslipidemia that has responded to dietary control and regular exercise.\r\n\r\nHis surgical and family histories are unremarkable. He has no known allergies.\n"}]}


{"ops":[{"insert":"\u0022Thanks for the information, Tim. Let\u0027s take a look at you\u0022, you say.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S25_F5.jpg"}},{"insert":"\n\n"},{"insert":"Tim\u0027s vital signs are normal. The general examination is unremarkable. His lungs are clear. His heart sounds are normal and no murmurs are heard.\n\nYou ask him to lie down and then sit upright. He does so and immediately says \u0022Doctor, I\u0027m feeling dizzy again!\u0022.\r\n\r\nAs you and Tim\u0027s wife, Eileen, help prevent him from falling off the bed, you notice rapid eye movements resembling nystagmus.\n\nOnce Tim has recovered his balance, you continue with the examination. \r\n\r\nThere are no focal neurological findings. The musculoskeletal examination is unremarkable.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S25_F6.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Perhaps I should perform...\u0022, you think and stop, as Mrs. Garcia whispers a question.\r\n\r\n\u0022Doctor, what do you think Mr. Vicari has?\u0022, she asks.\n\n\u0022I think that he has BPPV\u0022, you say with confidence.\r\n\r\n\u0022Got it\u0022, says Mrs. Garcia, nodding.\n"}]}