History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Relevant Mext Steps
Test Results
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Headache and dizziness in a 54-year-old man
Review of Systems
General
: Patient says he feels generally well except for the symptoms described. He denies fever, chills, night sweats, and weight loss. He feels unsteady when he walks, sometimes needing to hold onto a wall or railing for support.
Skin
: No rash or skin lesions noted.
HEENT
: Denies visual disturbances but notes a constant ringing sensation in his right ear. There is no sensation of pressure, and the ear is not painful. He says he has near-constant vertigo, which he describes as a sensation that the room is spinning around him, and he has trouble keeping his balance.
Pulmonary
: Noncontributory
Cardiovascular
: Noncontributory
Gastrointestinal
: No nausea, vomiting, or abdominal pain. Bowels moving normally.
Genitourinary
: Noncontributory
Musculoskeletal
: Occasional low back pain, which has worsened since he has been unable to exercise.
Neurologic
: Right temporal headache, denies difficulty seeing, speaking, or swallowing. No weakness or altered sensation.
Psychiatric
: Feels he is in his usual mood except for some anxiety about his current, worsening symptoms.
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