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The MKSAP Challenge

From the December ACP Observer, copyright © 2005 by the American College of Physicians.

Clinical scenario

A 45-year-old man is evaluated in the emergency department for nausea and severe dizziness. His symptoms developed earlier in the evening, awakened him from sleep, worsened when he attempted to sit up and caused him to fall on standing.

The patient noted no tinnitus. Thirty minutes of bed rest provided him with no relief. He has no history of dizziness or hearing loss and no other medical problems.

In the emergency department, his nausea improves with administration of intravenous fluids and prochlorperazine, but he needs help walking. On physical examination, pulse rate is 71/min, and blood pressure is 130/80 mm Hg. The tympanic membranes are intact. Diplopia, dysarthria, hearing loss and weakness are absent on neurologic examination. However, spontaneous nystagmus with a rotatory component is noted. Results of a Romberg test are positive, and a contrast-enhanced head CT scan is normal.

Which of the following is the most likely diagnosis?

A. Benign paroxysmal positional vertigo
B. Menière's disease
C. Perilymphatic fistula
D.Vestibular neuritis

Answer

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