A 56-year-old man comes to the office due to feeling "dizzy" over the past 2 weeks. The patient experiences a brief, severe spinning sensation when turning over in bed or looking up at objects on a high shelf. He has had no nausea, diaphoresis, chest pain, or tinnitus. Medical history is significant for long-standing hypertension and hypercholesterolemia. His father died of a stroke at age 62. On examination, a grade II/VI ejection murmur is heard at the left sternal border. Precordial palpation and carotid upstroke are normal. Which of the following is the most likely cause of this patient's symptoms?

Question

A 56-year-old man comes to the office due to feeling "dizzy" over the past 2 weeks.  The patient experiences a brief, severe spinning sensation when turning over in bed or looking up at objects on a high shelf.  He has had no nausea, diaphoresis, chest pain, or tinnitus.  Medical history is significant for long-standing hypertension and hypercholesterolemia.  His father died of a stroke at age 62.  On examination, a grade II/VI ejection murmur is heard at the left sternal border.  Precordial palpation and carotid upstroke are normal.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d47c_5e1c_bc81_e7237099ed97_MD0003_00 "Dizziness" is a common presenting concern of patients and may represent presyncope, disequilibrium, or vertigo. Vertigo is often described as a spinning (as in this patient), whirling, or tilting sensation and can be due to an underlying disease in either the central or peripheral nervous system. This patient's brief (<1 min), episodic vertigo triggered by head position changes (eg, turning over in bed, looking up) is consistent with benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo. BPPV is due to crystalline debris (canaliths) in the semicircular canals that disrupt the normal flow of fluid in the vestibular system. This leads to contradictory signaling from the corresponding canals on each side, which is interpreted as a spinning sensation (vertigo). The Dix-Hallpike maneuver can help diagnose BPPV: vertigo and nystagmus are triggered as the patient quickly lies back into a supine position with the head rotated 45 degrees. Treatment with canalith repositioning maneuvers (eg, Epley) is typically effective. canalith repositioning maneuvers (eg, Epley) (Choice A) Ménière disease is a disorder of the inner ear characterized by increased volume and/or pressure of endolymph (endolymphatic hydrops). Clinical features include episodic vertigo (20 min to 24 hr, as opposed to <1 min with BPPV), hearing loss, tinnitus, and aural fullness. (Choice B) Symptomatic arrhythmias are typically associated with palpitations and lightheadedness. Some patients may describe "dizziness," but positional vertigo would be extremely unlikely. (Choice C) Vestibular (brainstem) migraine causes vertigo that is variable in severity, typically lasts several minutes to a few hours, and is usually associated with headache or other migrainous phenomena (eg, photophobia). (Choice E) Severe aortic stenosis (AS) can lead to global cerebral hypoperfusion; however, this would cause lightheadedness or near-syncope rather than vertigo. Although AS can cause an ejection murmur, the murmur is classically best heard in the right (rather then left) sternal border and is associated with a delayed and decreased (rather than normal) carotid upstroke. (Choice F) Transient ischemic attacks of the cerebellum may present alongside episodic vertigo, but such episodes would not likely be triggered by changes in head position. Educational objective: Benign paroxysmal positional vertigo causes brief (<1 min) episodes of vertigo triggered by changes in head position. Dizziness related to cardiovascular causes (eg, aortic stenosis, intermittent arrhythmia) is usually due to global cerebral hypoperfusion and presents as lightheadedness or near-syncope rather than true vertigo. References: Recurrent spontaneous attacks of dizziness. (http://www.ncbi.nlm.nih.gov/pubmed/23042061) Dizziness and vertigo. (http://www.ncbi.nlm.nih.gov/pubmed/22377855)

A 56-Year-Old Man Comes to the Office Due to Feeling