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Dr.Wagner -> CASES (June 4, 2005 2:50:00 AM)
Back by demand... Sure, there are answers to these cases, they are intended for learning. PLEASE DO NOT GO ON THE INTERNET TO RESEARCH YOUR ANSWERS. The goal is to get honest "off your head" answers as if I was standing right in front of you presenting this. Please tell me the next step or how you would handle this patient. Also, ask questions if you like. I will respond likely tomorrow. Case#1 47 yo female patient of yours that you have been seeing for carpal tunnel syndrome recently tells you of how she had a bit of "dizzyness" over the weekend. She said it went away after a day, but it scared her. She thought it was strange as she had a headache at the same time. She tells you she has had headaches before but never with "dizzyness". What would you like to know??? What would you like to do? How do you manage? Case #2 50 yo male patient of yours that you have been seeing for low back pain recently tells you of how he has been experiencing "dizzyness" lately. He states they are accompanied by headaches and nausea. His headaches are usually frontal in origin. You have been seeing him for 1 month for back pain (intermittantly as he is a truck driver and works when he can). He says he had the headache when he came in to see you for todays appointment. What would you like to know and what would you like to do? Case #3 A 33 yo female arrives to your clinic today, you have been seeing her for neck pain related to a MVA, she trips on the new carpet you have in the waiting area but catches her fall. You ask her if she is "ok" and she tells you "yes, I am just a little dizzy" She seems to be acting a little strange today. You help her to the table and off handedly remarks that her "stomach hurts". What would you like to know? What would you like to do? Have a good one...all of these cases are real.

dosrinc -> Re: CASES (June 4, 2005 3:27:00 AM)
Doc, honest and off the top of my head, Case #1, being treated for carpal tunnel, I assume she is under the care of a neurologist, + hx of headaches, does her neuro know of this, are they migrane in nature, did she take anything in the past or this time for them. If no headache or dizziness now I go ahead and treat complete my regular treatment (does that include cervical work? would depend on my original eval) and advise her to contact her physician regarding headaches with dizziness. Case #2 Dizzyness + headaches + nausea and I am treating him for low back pain, he is referred back to his physician to assess. Case #3 Being treated for neck pain s/p MVA, new onset of dizzyness and nausea (stomach hurts). Did she have MRA post MVA, did we have any reason to suspect vert aa involvement during initial eval, how has she responded to treatments up to this point, getting better? worse? no change? Did she eat this am? Been dizzy in the past, prior to MVA or is this the first onset of symptoms like this, defintely call referring physician regardless of answers to these questions, make him/her aware of this change in presentation. Take a look at her eyes, watch tracking, nystagmus. Based on answers to these things I may feel comfortable trying some gentle active motions, very submax isometrics, see how she responds, does she feel better after getting some input to the subocc region, does head movement make her feel worse, would watch her very closely. Still acting " a bit strange" definitely check vitals. bp/hr, did she take meds this am, maybe this is a response to pain meds or mm relaxers, have they made her feel this way before? Neruontin sometimes creates these symptoms in folks, especially if she is just up in the morning. This is the toughest case, in my opinion, have to rely on experince and judgement. Thanks for waking me up this morning doc. Rick

KAK -> Re: CASES (June 4, 2005 7:12:00 AM)
I’m thinking a trip to the ER might be indicated in case #3. The acting strange and the nausea would frighten me-concerned about the vertebral artery. In the May JOSPT there was an interesting clinical commentary about there being little to no evidence that our VBI screening guidelines (including history and examination screenings) accurately identify patients at risk for VBI. This was discussed in light of manual therapy.

dosrinc -> Re: CASES (June 4, 2005 7:53:00 AM)
I know that the latest PTjournal has an Evidence in Action article regarding vert. aa testing, have not read it yet. Lots of debate in the journals regarding its use despite its inherent risks and poor validity/reliability. Rick

Dr.Wagner -> Re: CASES (June 5, 2005 2:55:00 AM)
I will leave the cases up a tad longer with the hopes of getting a few more responses... The goals are not necessarily to hear "send them to the doctor" but rather try to figure it out. Example, describe a test, tell me about your decision making. Tell me if you want to do an exam. I am trying to make this fun but yes, it is hard. I'll wait, I know there are alot of smart people wanting to play. I have heard alot of talk about differential diagnosis, lets see some in action.

SJBird55 -> Re: CASES (June 5, 2005 3:23:00 AM)
I'll respond a bit later. 3 cases and not enough time to type. I need to jump in the shower and head to mass.

Lukey -> Re: CASES (June 5, 2005 4:31:00 AM)
In each case I would want to have the patient define what they mean by 'dizziness', and in 1 and 2 what the quality of the the HA pain is. I would start with a neurological exam, incl cranial nerves and cerebellum, to look for more sinister causes. #1 Is she menopausal? Any signs of diabetes or hypothyroidism? #2 Any kidney problems? Any prodrome before the HA? Does he use drugs to stay awake when driving? #3 Has she been taking NSAIDs for the pain? Luke

SJBird55 -> Re: CASES (June 5, 2005 7:29:00 AM)
My second time responding since the first went who knows where because of some fatal error… I did NOT copy ideas from anyone either because I couldn’t get the site to work for me. Case 1: What is her definition of “dizziness?” Why is she frightened about her new symptoms over the weekend? What is her impression of what was going on? I’m not as concerned over this particular new complaint, but since she is, I would want to know her eating habits (is glucose levels a factor) and I’d be interested in any changes in caffeine intake. I’d review her medications, how long she has been taking them and whether anything new was recently introduced. I could listen at her carotids and check supine and standing blood pressures. I could also do some cervical positioning to see if I could provocate her symptoms. I’d ask her if similar symptoms ran in her family. If I didn’t find anything, I guess I really wouldn’t recommend much of anything. I’d recommend that if she was still truly scared, then she should communicate to her family physician. If she planned on communicating to her family physician, I would send a summary of her complaints and the responses to my questions and objective findings. Case 2: My initial gut reaction is a bit more concern for this guy. His age and his sedentary job are two factors combined with his complaints that increase my concern. Initially, my intuition tells me to consider gastrointestinal or cardiac/cardiovascular as being the source for his complaints. (I guess at worst, he could be having a mild myocardial infarction is what initially comes to my head.) I’d be curious as to his definition of “dizziness.” I’d be interested if he had any shortness of breath or any chest pressure. I’d be interested if he saw a pattern with eating habits. I’d be interested in what he reported with bowel movements. I would review his medications. I’d listen to his carotids and get vitals. Palpating near the abdominal aortic region could be done and palpating for femoral and tibial pulses could also be done. I’d gather the data and then keep him in house while I contacted his primary care provider to report his change in presentation and receive guidance as to what the primary care provider recommends. Case 3: My initial response is that this person needs to be medically seen. I say that, but you can be tricky sometimes… so, I’d first ask you if I smelled any particular odor with her (i.e. alcohol)? I’d also want to know if she thought she was going to puke and I’d definitely help her get where she needed to be so that I wouldn’t have a mess to clean nor join her in that physical act. :) (If she did puke, I’d want to know what she barfed.) I’d like to have a better understanding of what you mean by “acting strange.” Her complaints could be neurological, gastrointestinal, vestibular issues – or they could be induced via medications or substances she is allowing to enter her body. Am I able to notice a change in her cognition? Any change in her vision? I could assess her cranial nerves. I could use a tuning fork to assess her vestibular system. I could assess coordination. She might have a slow bleed in her brain depending on how long ago the MVA occurred… she might even have a slow bleed in the abdominal aortic region again depending on how long ago the MVA occurred. She might have a brain tumor. The only other thing might potentially be cervical instability? I would definitely contact her primary care provider regarding her change in status. She would not be allowed to leave the clinic and drive away independently because I’m thinking she’d be a risk to herself and potentially to the public. Responding to cases is always difficult, in a way… even in all 3 cases, I don’t know exactly what I’d do because it all depends on the answers to some of the questions.

Dr.Wagner -> Re: CASES (June 5, 2005 11:07:00 AM)
Case 1 She tells you "my eye hurts primarily when I have the headache" "It doesn't hurt now, but I do see double" You attempt to do a "Hall-Pike menuever" and she becomes more "dizzy" She defines "dizzy" as the "room spinning" She has a fast beating Nystagmus to the right. Her medications are Tylenol It is a saturday and her doctors office is closed. a)so what is her "dizzyness" defined as? b) "listening to the carotids" was mentioned...why would you do that? c) how do you name the Nystagmus, how is it significant d)What part of the cranial nerve exam is important in her case...be specific Case 2 This guy vomits in front of you. He denies chest discomfort. But states his "dizzyness" is like he is spinning but he felt "like the room was going dark" before. He denies abdominal pain. He states he recently had a heahache. He needs to sit down. His medication is Tylenol He does not smoke, he has no significant family history or past med history. It is in the middle of winter, and his doctors office is closed. Really cold outside. a) why listen to his carotids? b) what are his risk factors for cardiac disease? c)What part of the physical exam do you wish to pursue (if any) d) how do you define his "dizzyness" Case #3 She says she wants to go home. Her meds include Vicodin and ibuprofen. a) can she go home? b) you suspect potential narcotic abuse, what part of the physical exam may lead you to that conclusion c) What significance is her abdominal pain? d) Why would she get an MRA? Is this routine? How much does a MRA cost?

SJBird55 -> Re: CASES (June 5, 2005 1:14:00 PM)
Case 1: Her dizziness seems more vestibular in nature. I mentioned the carotids only because "dizziness" can mean different things to different people - I was thinking more in the lines of lightheadedness and with that thought was wondering about any blood blockage to the brain which would mean maybe hearing bruits. I would need to look up the nystagmus thing - one of those things I'm sure I learned, but have never seen with a patient (ah, but I do know where to look for the answer). And beats me which specific cranial nerves, but it would be the nerves that are involved when double vision occurs if they have a lesion (again, something I'd just look up). Case 2: EWWW... I don't do good with vomit and I'm sicker than a dog with him. :) Again, carotids for bruits. male, 50, sedentary job I'd still do what I initially said I'd do. That cold outside was a clue, wasn't it? Doesn't that potentially indicate MI? I'd see his dizziness being more closely related to lightheadedness with a potential of fainting. Case 3: You still haven't answered the things going around in my brain on that case. I would have no idea how to know if there is narcotic abuse - maybe pupils and vitals, unless of course there are needle marks, but I don't believe you are referring to that kind of abuse. Can Vicodan and ibuprofen be taken simultaneously? That's something else I'd have to look up. Is the abdominal pain significant? If the ibuprofen is eating through her gut, that might be a potential cause?

VagusX -> Re: CASES (June 6, 2005 10:46:00 AM)
As far as Case 3: I imagine she is doped up hard and she took more than 4800 mg of APAP causing abdominal discomfort. Taking lots of vicodan can make somebody nautious and dizzy anyway. Ask her how much she took then have her vomit if she took an overdose amount. Send her to ER. I'll have time to answer the other two later.

USAPT -> Re: CASES (June 7, 2005 9:22:00 AM)
Case 1: What was she doing when she became dizzy? Did she eat that day? She may possibly be suffering from migraines. Worst case scenario vertebrobasilar artery disease (i.e., clinical s/s: diplopia, dizzy, HA). Could be chronic renal failure..s/s can mimic CTS. Does she have any pain anywhere else?.(i.e. R shoulder/ medial scapular pain?) I know that's jumping to conclusions but you have to also recognize all possibilities. I would want to know if she had any c/o numbness or other "abnormal" symptoms at any time). I would check all CNs but specifically II, III, IV, V, VI, VII, VIII, IX, X, XII (motor & sensory) of pertaining CNs. Also Bp, HR, RR. A functional position to test VA is have pt sit slouched (places c/s in backward bending) and check AROM--> evaluate integrity of eye mov't. Despite results, I would document and notify GP and depending on results, I may or may not continue with rx. Are her worse during menstruation? Case 2: Initial gut reaction is that it isn’t his back at all. More than likely it is referred pain from a GI issue. Without cheating, I can’t recall specifics (but like SJBird55, I know where to find it). Possibly a peptic ulcer? (The chronic use of NSAIDS can predispose an individual to an ulcer but as long as they are taking meds they won’t necessarily notice/feel it, but once the meds stop, all of a sudden the s/s are present and have really been there all along). What are his eating habits? What are his bowel movements like (hard, soft, blood, color?). I’m sure there is more but I can’t think right now. Case 3: Through talking to her, I would smell her breath for possible alcohol. Also, observe her body language and speech. I would tell her we were going to do some tests (vision CNs II, III, IV, CNVI and for balance CNVIII). Did she eat today? Last night? Is she possibly hung over? Did she take pain meds w/o food and or w/ ETOH? What time of days is it? And how long have we been treating her?(will give you a better idea of her) On a different note, is she menopausal? If this is an acute condition, these s/s may be from VA insufficiency. I wouldn't send her home but to the ER Doc, that's the best I could do w/o cheating:)

MPT -> Re: CASES (June 7, 2005 1:13:00 PM)
Case 1: I would want to know if she had any changes in her hearing. Head on trunk motion vs trunk on head. Case 2: What is he wearing (no idea on this one) :confused: Did we get vital signs on him. Case 3:Are her pupils dialated. Lets give her some narcane and see what happens :)

jbeneciuk -> Re: CASES (June 7, 2005 6:38:00 PM)
Doc Wagner: Sorry I've missed out on all of the fun !! I've had some medical problems myself, doing fine now...I'll try to join in from your last questions: 1) a) dizziness with Dix-Hallpike combined with findings of horizontal nystagmus, as opposed to vertical nystagmus..I would suspect a vestibular origin of dizziness..if I remember correctly vertical nystagmus is of neurologic origin and would be considered an emergency ?? b) CN exam: II, III, IV, VI (vision) pupil reaction tests to light motor ability to track moving object c)because the attempt to perform the Hall-pike dix increased her sx of dizziness...I would attempt an Epley maneuver...after explaining to the pt why it was going to be performed and what to expect...close monitoring of her sx and reports of vision would determine if I proceeded with the maneuver or not. 2) a)dizziness defined; room spinning (possible vestibular), however "room going dark" concerns me b) sx listed alone sound like migraine...sensitivity to light, vomitting, nausea...however there are other factors which could suspect a more serious patholgy (temporal arteritis)?? c) checking his vitals would be called for d)the fact that he presented as he did, his sedentary lifestyle, combined with his headaches and supposed sensitivity to light are too many factors to feel comfortable with sending him home immediatley...monitor his sx, follow-up with physician....would not pursue with any treatment today. 3) a) suspect narcotics, possible addiction to Vicodin ?? b) can she go home: if narcotic abuse suspected, I would communicate my suspicions with the physician, however it could be she is having adverse reactions to her medications and not abusing, which could be a serious problem. I would attempt to contact her emergency contact to pick her up, or get her a cab...hold-off on treatment until I speak with her physician. *These case studies are awesome and they really humble me...this should be a regular thread...you have alot of free time right Doc ? Thanks JBeneciuk

jessicau08 -> Re: CASES (June 8, 2005 2:53:00 AM)
Case 1: I would get out my otoscope and check for papilledema just in case?? I would test a few pathological and DTR reflexes too. My concern is that her vision, neuropathy, dizzy, headache is CNS oriented with either ALS or MS type lesions or tumor affecting multiple structures in the brain. Like her to get a neurology consult. Recently read of unusual presentation of ALS in women I think but I can't exactly be sure. Case 2: Has he been shoveling snow with a bad back?? #1 cause of MI, or is that just an urban legend we hear in the south? But really, check his body temp. and stay far away, it sounds like a bad flu. My very first thought before the cold weather info was slow leaking abdominal aneurysm (non arterial locale) LBP, lights dimming, dizzy, maybe follwed by pain/pressure which he denies now, that would manifest as blood built up inside the abdominal cavity. Check BP while you call 911! Case 3: Check her chart for meds currently prescribed. Compare possible side effects with her apparent state. Is she undermedicated for her level of pain and compensating with excessive dosing? Consult with her doctors office before allowing her to leave, and based on their info have a talk with the patient about her meds and the side effects to see if she offers any insight.(i.e. excessive dependence) Examine her cerebellar functioning and pupil response and visual tracking to assess if under the influence of substances. Explain that due to her unsteady footing earlier and her not feeling 100% today you would like to call a friend or family member to escort her home. Ibuprofen = GI irritation

chiroortho -> Re: CASES (June 8, 2005 6:35:00 AM)
[QUOTE]I would get out my otoscope and check for papilledema just in case??[/QUOTE]Yeah, papilledema of the eardrum is always a bad thing. :)

chiroortho -> Re: CASES (June 9, 2005 2:50:00 PM)
Hey, I was just kidding! (notice the smiley face). Don't want to see the thread end like that.

MPTSTUDENT -> Re: CASES (June 9, 2005 3:49:00 PM)
So Dr. Wagner what is the final verdict?

Dr.Wagner -> Re: CASES (June 10, 2005 8:43:00 AM)
I apologize for the delay...I moved into a new home and have no internet for the week. Once again, these are REAL cases of mine...all that develope around the concept of "dizziness". Furthermore stressing the idea of a BROAD and valuable differential, looking past the terms "vestibular" a highly overused term taught in many PT schools that simply will get you into trouble. Case 1. Young woman, vertigo, eye pain, headache, nystagmus, diplopia...eye movement disorder...internuclear opthalmoplegia...what is this???? Think. Case 2. Truck driver, nausea, vomitting, vertigo, lightheadedness, in the middle of winter...perhaps he has a portable heater in his truck??? What is this? Epidemic in the winter in the north. Case 3 MVA..."acting weird" taking vicodin...yep, this is narcartic intoxication...the abdominal pain is from...constipation. Can't poop, hasn't for days. Narcotics are notorious for all of these symptoms. So can she go home from the clinic?

chiroortho -> Re: CASES (June 10, 2005 8:57:00 AM)
I've tried to stay out of this, but these are interesting. [QUOTE]internuclear opthalmoplegia[/QUOTE]This in and of itself is MS until proven otherwise. I would have expected to see optic neuritis on opthalmologic exam, but this was not mentioned. [QUOTE]Truck driver, nausea, vomitting, vertigo, lightheadedness, in the middle of winter...perhaps he has a portable heater in his truck??? What is this? Epidemic in the winter in the north.[/QUOTE]The poor sap is suffering from CO poisoning. [QUOTE]So can she go home from the clinic?[/QUOTE]Now (for me anyway) this is tougher. Your ED nurse has written in this patient's chart that she appears narcotized because of her miotic pupils and slurred speech. But (and I suspect that this is where I screw up) I would send her to Medicine with a recommendation for a laxative and psych consult for substance abuse. Thanks for the cases. The ED must be a daily adventure.

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