A 55-year-old woman is brought to the emergency department due to severe dizziness and unsteadiness. Two days ago, she awoke with a spinning sensation accompanied by severe nausea and vomiting and a feeling of pressure in the right ear. The episode lasted an hour. Over the next 48 hours, the patient had similar events while in bed. She had no tinnitus, headache, blurry or double vision, dysphasia, dysarthria, falls, or focal weakness during the episodes. The patient has no history of neck or head trauma. She was evaluated for similar symptoms 2 months ago, and no medication was prescribed.
Medical history is notable for type 2 diabetes mellitus, which was diagnosed 15 years ago and is complicated by peripheral neuropathy and gastroparesis. The patient also has hypertension, hypothyroidism, and hyperlipidemia. Family history is notable for stroke and heart disease.
Temperature is 37 C (98.6 F), supine blood pressure is 130/85 mm Hg, and supine pulse is 88/min and regular. Weber test shows lateralization to the left ear. Rinne test shows diminished air and bone conduction on the right and normal findings on the left. Sensory examination reveals a length-dependent reduction in pain, temperature, vibratory, and proprioceptive perception in the lower extremities up to the knees and in the upper extremities up to the elbows. Reflexes are absent in the lower extremities and 1+ in the upper extremities, with mute plantar responses. Coordination testing is normal. A bedside Dix-Hallpike maneuver does not elicit nystagmus.
Which of the following is most likely to prevent further symptoms in this patient?

Question

A 55-year-old woman is brought to the emergency department due to severe dizziness and unsteadiness.  Two days ago, she awoke with a spinning sensation accompanied by severe nausea and vomiting and a feeling of pressure in the right ear.  The episode lasted an hour.  Over the next 48 hours, the patient had similar events while in bed.  She had no tinnitus, headache, blurry or double vision, dysphasia, dysarthria, falls, or focal weakness during the episodes.  The patient has no history of neck or head trauma.  She was evaluated for similar symptoms 2 months ago, and no medication was prescribed.
Medical history is notable for type 2 diabetes mellitus, which was diagnosed 15 years ago and is complicated by peripheral neuropathy and gastroparesis.  The patient also has hypertension, hypothyroidism, and hyperlipidemia.  Family history is notable for stroke and heart disease.
Temperature is 37 C (98.6 F), supine blood pressure is 130/85 mm Hg, and supine pulse is 88/min and regular.  Weber test shows lateralization to the left ear.  Rinne test shows diminished air and bone conduction on the right and normal findings on the left.  Sensory examination reveals a length-dependent reduction in pain, temperature, vibratory, and proprioceptive perception in the lower extremities up to the knees and in the upper extremities up to the elbows.  Reflexes are absent in the lower extremities and 1+ in the upper extremities, with mute plantar responses.  Coordination testing is normal.  A bedside Dix-Hallpike maneuver does not elicit nystagmus.
Which of the following is most likely to prevent further symptoms in this patient?

Quizplus · Accepted Answer

11ec193a_95eb_d120_853d_71cbb3b7c62b_MD0002_00 This patient has Ménière disease, a disorder of the inner ear characterized by increased volume and pressure of endolymph (endolymphatic hydrops). The resulting distension of the endolymphatic system damages the vestibular and cochlear components of the inner ear. Ménière disease is characterized by: Episodic vertigo, typically lasting 20 minutes to several hoursSensorineural hearing loss, variable in severity but usually progressiveLow-frequency tinnitus and/or a feeling of fullness in the affected ear Episodic vertigo, typically lasting 20 minutes to several hours Episodic vertigo, typically lasting 20 minutes to several hours Sensorineural hearing loss, variable in severity but usually progressive Sensorineural hearing loss, variable in severity but usually progressive Low-frequency tinnitus and/or a feeling of fullness in the affected ear Low-frequency tinnitus and/or a feeling of fullness in the affected ear The diagnosis of Ménière disease is based primarily on clinical findings. Although not all patients have tinnitus, a perception of aural fullness associated with episodic vertigo and sensorineural hearing loss is specific for Ménière disease. Audiometry is helpful for fully characterizing hearing loss and following its course over time. Initial management includes restriction of sodium, caffeine, nicotine, and alcohol. Benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms. Diuretics can be considered if dietary changes are insufficient. (Choice A) Canalith repositioning maneuvers (eg, Epley maneuver) are helpful for treating benign paroxysmal positional vertigo (BPPV), which usually has shorter episodes (seconds to minutes) than Ménière disease. This patient's aural fullness, hearing loss, and negative Dix-Hallpike maneuver make BPPV less likely. (Choice B) Aspirin is indicated for prevention of recurrent transient ischemic attack or stroke, which occasionally causes vertigo but usually presents with additional deficits. This patient has no motor deficits, and the abnormal sensory findings and reflexes are likely due to diabetic neuropathy. (Choice C) Midodrine is a vasopressor used to treat orthostatic hypotension in the setting of dysautonomia. Although this patient does have autonomic diabetic neuropathy, it would not explain her vertigo or hearing loss. (Choice D) Oral glucocorticoids (eg, methylprednisolone) can treat acute vestibular neuritis, which typically follows a viral infection and presents with a single prolonged episode of vertigo and gait instability. Hearing loss may also be present (termed labyrinthitis), but this patient's episodic symptoms are more consistent with Ménière disease. Educational objective: Ménière disease is characterized by episodic vertigo, sensorineural hearing loss, and tinnitus and/or a feeling of fullness in the ear. The diagnosis is based primarily on clinical findings. Initial management includes restriction of sodium, caffeine, nicotine, and alcohol. Diuretics can also be useful. __________ References: Meniere's disease: an evidence based approach to assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/22257041)

A 55-Year-Old Woman Is Brought to the Emergency Department Due