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Solve the Medical Riddle: She Constantly Feels as Though She’s Swaying and Rocking, First Week

 

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told the doctor and how the doctor proceeded with the examination. Next week, the doctor will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient’s Reports Her Symptoms

Judy, a 53-year-old high school English teacher, presented with the constant sensation that she was swaying and rocking.
Her doctor used the classic S-O-A-P notes as follows:
S=Symptoms or Chief Complaint
O=Objective Findings
A=Assessment or Analysis
P=Treatment Plan or Recommendations

This week, we’ll cover S, Symptoms or Chief Complaint. Here’s what Sally told the doctor:

“For about two years, I’ve had the constant feeling that I’m swaying and rocking. I also have ‘brain fog’, I’m exhausted all the time, I don’t sleep soundly, and I have frequent headaches. I’ve missed many days of work because I just haven’t felt well enough to deal with classrooms full of teenagers. I kept telling myself this would pass when I got through menopause but I had my last period a year ago and I’m still feeling terrible.

“The weird thing is that when I’m in the car, whether driving or riding, the swaying sensation stops. But then it comes right back when I get out of the car and I’m always afraid of falling. I hope you can help because this problem is making my life miserable!”

After hearing Judy’s complaint, the doctor suspected that it could be vestibular in origin. The vestibular system, including the cochlea and vestibule. of the inner ear, is the sensory system that contributes to balance and spatial orientation. The doctor proceeded with a thorough evaluation for a differential diagnosis, which in laymen’s language simply mean eliminating possible conditions or causes.

The PCP started the evaluation process, but she let Judy know that she would give her a referral for an MRI to rule out right away the remote but potentially serious possibility of a brain tumor, and that she would also give Judy a referral either to a neurologist or an otolaryngologist (Ear, Nose Throat specialist, ENT) depending on thoughts and concerns after the initial examination.

First, the doctor asked Judy to describe in as much detail as possible what she recalled about the onset of the problem. What was going on about two years ago when it all started? Judy had not kept a “health journal”, always a good idea when dealing with new symptoms, so she had to rely on her memory. Here’s what she came up with at the first visit:

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