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Case records of the Massachusetts General Hospital. Case 34-2013. A 69-year-old man with dizziness and vomiting.

Dr. Minjee Kim (Neurology): A 69-year-old man was admitted to this hospital because of dizziness and vomiting. The patient had been well until 4:15 a.m. on the day of admission, when he became dizzy, diaphoretic, and weak and had sensations of rocking and counterclockwise movement after he rolled onto his stomach in bed. The symptoms improved when he rolled into the supine position, and he slept until 7 a.m.; on awakening, the symptoms recurred. When walking, he sensed he was tilting to the left but did not fall. The symptoms worsened throughout the morning; they were most severe with head movements and were associated with increasing nausea and, after 10 a.m., vomiting. He called his doctor’s office because of concern that he was having a stroke. He was advised to go the hospital and called emergency medical services. On examination, his skin was pale and dry and the blood pressure was 148/60 mm Hg; the other vital signs and the remainder of the examination were normal. He was brought to the emergency department at this hospital, arriving approximately 9 hours after the onset of symptoms. The patient reported facial tingling in the area surrounding the eyes, including the malar eminence, and a mild headache. He noted that his visual perception momentarily lagged behind his eye movements, and the lag was more severe when looking to the right than to the left. He had no diplopia, blurred vision, tinnitus, decreased hearing, difficulty swallowing, changes in sensation or strength, palpitations, chest pain, fever, or shortness of breath. He reported an episode of self-limited positional vertigo that had occurred several years earlier. He had hypertension, hyperlipidemia, asthma, sleep apnea (for which he intermittently used continuous positive airway pressure at night), depression, meralgia paresthetica (a painful mononeuropathy of the lateral femoral cutaneous nerve), erectile dysfunction, and recurrent localized herpes simplex virus infection. He was left-handed. His daily medications included rosuvastatin, valsartan, hydrochlorothiazide, duloxetine, aspirin, and a multivitamin. He also received, as needed, a topical lidocaine patch for meralgia paresthetica; gabapentin for pain; vardenafil (though he had not taken it recently); fluticasone propionate nasal spray and inhaler, albuterol, and Case 34-2013: A 69-Year-Old Man with Dizziness and Vomiting