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Posted March 17, 2025THE WORST DIZZINESS EVER
Medical Case Study
Our patient is a 50-year-old retail professional who trades smoked fish and prides herself on her resilience. Despite juggling long hours at work, managing a household, and caring for her two children, she has always considered herself "healthy enough." Over the past year, she began experiencing symptoms that could no longer be ignored. Mornings started with hacking coughs producing clear sputum. Her right arm, once strong, ached when she tried to comb her hair. Turning her head at night triggered severe vertigo. Sleep was fragmented by snoring, and daytime fatigue left her dragging through her shifts. By the time she sought care, her symptoms had formed a complex pattern, demonstrating that seemingly disparate symptoms often share hidden connections.
Case Presentation
A 50-year-old retail professional presents with a constellation of symptoms progressively worsening over the past year. Despite her resilience in managing long work hours, household responsibilities, and caring for her children, she is overwhelmed by persistent health issues.
Chief Complaints:
Acute dizziness (9 hours)
Right arm pain with difficulty raising it (1 week)
Chronic productive cough (several months)
History of Present Illness:
Dizziness: Sudden-onset positional vertigo triggered by head movements or lying down, associated with right-beating nystagmus.
Right Arm Pain: Aching pain localized to the armpit, worsening when raising the arm above the head, with discomfort in the right neck, face, and ear.
Chronic Cough: Recurrent morning cough producing clear sputum, no fever, chest pain, or shortness of breath. Snoring and daytime fatigue reported.
Physical Examination Findings:
Vitals: BP 129/82 mmHg, Pulse 62 bpm, Temp 37°C, Respiratory Rate 18/min, BMI 39.84
Neurological Exam: Right nystagmus on positional changes; cranial nerves intact; no focal motor deficits
ENT Exam: Tender right maxillary sinus, swollen nasal turbinates in the right nostril, dull right tympanic membrane
Musculoskeletal Exam: Limited range of motion in the right shoulder due to pain in the rotator cuff muscles
Cardiopulmonary Exam: Clear lung fields; regular heart sounds with no murmurs
Abdominal Exam: Soft, non-tender abdomen with no palpable masses
Diagnostic Findings:
Laboratory Tests: Microcytic hypochromic anemia with anisocytosis and lymphocytosis; fasting blood sugar 4.8 mmol/L (normal)
Imaging:
Neck scan: Normal carotid vessels, thyroid, and swallow movement; thick neck noted
Chest X-ray: Clear lungs
Echocardiogram: Normal ejection fraction, no wall motion abnormalities
Abdominal ultrasound: Fatty liver, uterine fibroids, otherwise normal
Shoulder ultrasound: Hyperechoic signals in the right rotator cuff tendons
Diagnoses:
Acute Dizziness: Benign Paroxysmal Positional Vertigo (BPPV)
Presentation: Sudden-onset positional vertigo with right nystagmus
Management: Epley maneuver
Chronic Cough and Right-Sided Facial/Ear Symptoms: Allergic Sinusitis
Presentation: Productive morning cough, right maxillary sinus tenderness, swollen turbinates, dull tympanic membrane
Management: Nasal corticosteroids, antihistamines, saline irrigation; evaluate for GERD
Right Shoulder Pain and Limited Mobility: Rotator Cuff Tendinopathy
Presentation: Aching pain in right armpit, limited range of motion, tenderness in rotator cuff muscles
Management: Physical therapy, NSAIDs, activity modification
Obstructive Sleep Apnea (OSA)
Presentation: Snoring, daytime fatigue, crowded oropharynx, obesity (BMI 39.84)
Management: Sleep study, CPAP initiation
Iron Deficiency Anemia
Presentation: Microcytic hypochromic anemia with anisocytosis
Workup: Ferritin, iron studies, endoscopy/colonoscopy if indicated
Obesity and Comorbidities
Impact: Exacerbates OSA, joint pain, fatty liver, pre-diabetes
Management: Weight loss through diet, exercise, and possibly medical/surgical interventions
Final Diagnoses:
Benign Paroxysmal Positional Vertigo (BPPV)
Allergic Sinusitis with Postnasal Drip
Rotator Cuff Tendinopathy
Obstructive Sleep Apnea (OSA)
Iron Deficiency Anemia
Obesity with Associated Comorbidities
Management Summary:
Immediate interventions include the Epley maneuver for BPPV, nasal corticosteroids for sinusitis, and physical therapy for the shoulder. Diagnostic priorities include a sleep study, iron studies, and evaluation for gastrointestinal bleeding. Long-term goals focus on weight loss, CPAP adherence, and management of uterine fibroids.
Discussion:
This case highlights the interplay between chronic conditions, lifestyle factors, and anatomical vulnerabilities. Positional vertigo from BPPV may be exacerbated by obesity and OSA. Chronic allergic sinusitis contributes to cough and facial pain, which is further worsened by sleep disturbances. Shoulder tendinopathy is aggravated by repetitive overhead movements and poor sleep posture. Iron deficiency anemia likely results from chronic uterine fibroid bleeding, contributing to fatigue and delayed healing. Obesity amplifies every condition, including OSA, joint stress, and fatty liver.
Patient-Centered Path Forward:
Immediate Relief: Epley maneuver, nasal corticosteroids, physical therapy
Diagnostic Priorities: Sleep study, iron studies, GI evaluation
Long-Term Goals: Weight loss through nutrition and exercise, CPAP adherence, fibroid management
This case underscores the importance of a holistic, multidisciplinary approach. By treating the patient as a whole person, clinicians can unravel complex, interconnected symptoms and restore both health and quality of life.