Feedback and Diagnosis, Chicago Dizziness and Hearing

I got a copy of the write-up that was made by Dr. Cherchi, the doctor I visited regarding my dizziness recently.

This info was written to me, and also sent to my regular physician. In reading over it, I got a kick out of some of the language and phrasing. It made me laugh at several points, and I thought it worth posting up here. Since this is my medical info, I presume I’ve got every right to share whatever I feel like. So here goes.

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IMPRESSION
Given his history and normal neurological examination, I am uncertain of his diagnosis, but I am reassured by the fact that the symptoms appear to have resolved spontaneously. Differential diagnostic considerations include mild vestibular neuritis (with subsequent episodic irritability triggered by metabolic changes such as caffeine or hyperventilation) and anxiety.

PLAN
1) Since his symptoms appear to have resolved, no intervention is necessary at the moment.
2) If symptoms return, I would like to reexamine him when he is symptomatic. I will also recommend doing audiometry, otoacoustic emissions, vestibular evoked myogenic potentials, and computerized dynamic posturography.
3) If that is unrevealing, then I would consider empiric treatment with a low dose of a benzodiazepine as needed.

HISTORY OF PRESENT ILLNESS
This 35-year-old gentleman, with no relevant past medical history, presented to clinic with a chief complaint of an episodic “tilting” sensation that “feels like I am on a slow conveyor belt.” This sensation began gradually around June 2009. It usually occurs during work hours, typically when standing still and is more frequent in the afternoon.

There is no clear dietary trigger except perhaps excessive caffeine intake. The sensation appears to have resolved during the past several weeks. The patient questions whether it might be related to stress since it was completely absent during the non-stressful period of his recent honeymoon.

Otologically, he denies tinnitus, noise sensitivity, ear fullness, otalgia, and hearing loss on either side. He gets headaches about once every four to six months and does not consider them significant.

On review of systems, he denies fevers, unusual bleeding, and a new cough. He has had a mild weight gain recently.

LIFESTYLE
He has one alcoholic drink every one to two days. He does not smoke. He adds a minimal amount of salt to his diet. He works as a Manager for Emmis Interactive. He travels by airplane infrequently. He is neither in litigation nor disabled. He is able to drive. He sleeps with one pillow, habitually on his back or with the right side down.

INJURIES OR EXPOSURES
No trauma to the ears, head, or neck. No unusual noise exposure.

PAST MEDICAL/SURGICAL HISTORY
No particular motion sensitivity during childhood. Stress at work. Obstructive sleep apnea, currently using CPAP.

EXAMINATION
He was pleasant and cooperative. Blood pressure 116/80. Pulse: 84. Respirations: 16. Weight: 193 pounds. Height: 67 inches. Regular cardiac rhythm. There were no cardiac murmurs and no carotid bruits. Normal tympanic membranes under binocular microscopy. Normal unsighted tandem Romberg stance. Reflexes, planar responses, strength, gross sensation, and cerebellar system function were normal bilaterally.

This Post Has 4 Comments

  1. That lifestyle paragraph is the BEST!! Pure poetry…

    Jane Reply


  2. My favorite was that he was ‘pleasant and cooperative’. heh

    Liz Reply


  3. I love that you just thew the whole thing out there and opened up your medical report to us!! You’re so brave. I’m fascinated by this sentence: “He is neither in litigation nor disabled.”So basically, he doesn’t know what’s wrong with you but if it happens again he wants to see you as it’s happening. If he can’t figure it out then, he’s going to give you Xanax or Valium (benzodiazepine). :)

    Layla Reply


  4. I was surprised at the litigation comment too. I wonder if that typically induces levels of stress that could cause similar symptoms?I don’t think of posting this as brave. I just found a lot of it funny.Is THAT what benzodiazepine is? I could have gotten Valium out of the deal? Dangit.

    avoision Reply


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