Case Study 4: My World Is Spinning

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 4: Min—My world is spinning

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A 62-year-old woman comes to see you about repeated episodes of spinning vertigo over five days, which gradually improved. Today (day 7), she gets 15–45 seconds of vertigo brought on by movement such as rolling over in bed. She denies tinnitus, hearing loss, or neurologic symptoms.

She has hypertension treated with an angiotensin receptor blocker and T2 diabetes treated with metformin and an SGLT-2 inhibitor. In the clinic, P is 82, BP 112/69. She has decreased vibratory sensation in her great toes bilaterally. Protective sensation is intact with a 10 gm monofilament. A Dix-Hall-Pike maneuver was performed. Her vertigo could be reproduced with the right ear downward. Rotatory nystagmus was seen during the maneuver.

Question

What is the most likely diagnosis?

The most likely diagnosis is BPPV (benign paroxysmal positional vertigo, a.k.a. benign positional vertigo=BPV). This history and exam is classic for BPPV. When the history is less obvious, checking orthostatic pulse and blood pressure, checking hearing specifically in each ear and a screening neurological exam including a CV exam for irregular heart rate and a vascular exam for pulses and bruits can be helpful. Always consider medication side effect. Patients with Meniere’s disease classically have tinnitus and hearing loss, though it may be subtle. Metformin can precipitate B12 deficiency. Management of BPPV is canalith repositioning (Eply manuever).

The eply manuever

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