Acute Shortness of Breath and
Lightheadedness in a 64-Year-Old
Female/IHUMAN CASE WEEK #9, CLASS
6550, FOR A 64-YEAR-OLD FEMALE
PATIENT. REASON FOR VISIT SHORTNESS OF
BREATH AND LIGHTHEADEDNESS
Mr. Jones is a 67-year-old male brought into your office because he has been having "dizzy
spells and room spinning" for the past two days that are intermittent. Your records indicate a
history of back pain, diabetes and hypertension. Upon further questioning, Mr. Jones cannot
identify when these spells come on and nothing seems to relieve them. His temperature is 98.6
Fahrenheit; blood pressure is 165/95 mmHg; heart rate is 78 beats/minute; and respiratory rate
is 18 breaths/minute. On physical exam, you notice a slight nystagmus. You ask him to focus on
your nose but the nystagmus continues.
What is the most likely cause of his "dizzy spells"?
A. Anemia
B. Bleeding gastric ulcer
C. Hyperthyroidism with thyroid storm
D. Stroke
E. Vestibular neuritis - answer-D.
This patient displays symptoms of vertigo and findings of nystagmus suggesting a neurologic
problem with balance. Thus, anemia (A), bleeding ulcer (B), and thyroid storm (C) - all of which
may present with presyncope (but should not cause vertigo) - are not likely diagnoses. He is
likely suffering from a central lesion (ie: TIA/stroke) causing vertigo. The acute onset of
symptoms, nystagmus that changes direction and nystagmus that does not resolve with gaze
1
, fixation are consistent with a central lesion as opposed to a peripheral lesion. In a peripheral
cause, such as vestibular neuritis (E), one would expect the patient's nystagmus to resolve upon
focusing on your nose.
You are seeing a 54-year-old female with a past medical history of kidney stones who presents
with a chief complaint of "I have a terrible summer cold." She reports three days of low grade
fevers (peak of 100.0 Fahrenheit), cough, sore throat, headaches, and nasal congestion. She
denies myalgias. Her temperature today is 99.2 Fahrenheit, respirations 14/minute, pulse 78
beats/minute, and blood pressure of 128/74 mmHg. Her head and neck exam reveals normal
tympanic membranes, mildly congested nasal turbinates with thin mucous, erythema of the
tonsillar pillars and soft palate without tonsillar enlargement or exudate, and mild anterior
cervical lymphadenopathy. Her lungs are clear to auscultation.
Which of the following options would be the most appropriate therapeutic option for this
patient?
A. Echinacea supplementation
B. Oseltamivir (Tamiflu) 75 mg twice daily for five days
C. Pseudoephedrine (Sudafed) as needed f - answer-C.
This patient has the symptoms and physical exam consistent with the acute infectious
rhinosinusitis (ie. the common cold). Treatments that have been demonstrated to help
symptoms of the common cold include decongestants such as pseudoephedrine (C), nasal
ipratropium spray, and (with weaker evidence supporting it) vitamin C. Vitamin C (D) would be
inappropriate in this patient because it can cause kidney stones, which she has had in the past.
Zinc (E) and echinacea (A) have not been demonstrated to consistently improve symptoms of
the common cold. Oseltamivir (B) is a treatment for influenza, which typically has outbreaks in
the winter and typically causes higher fevers and prominent myalgias.
You are seeing a 60-year-old male brought into your office because of "dizzy spells where he
almost passes out" for a week. Your records indicate a history of back pain and diabetes. Upon
further questioning, he says he sometimes feels like he is going to pass out and gets short of
breath after walking about half a block. He's never felt this way before. He denies having a
spinning sensation when he is dizzy. His back has also been really bothering him for the past
several weeks so he has been taking ibuprofen "all the time." His temperature is 98.6
2
Lightheadedness in a 64-Year-Old
Female/IHUMAN CASE WEEK #9, CLASS
6550, FOR A 64-YEAR-OLD FEMALE
PATIENT. REASON FOR VISIT SHORTNESS OF
BREATH AND LIGHTHEADEDNESS
Mr. Jones is a 67-year-old male brought into your office because he has been having "dizzy
spells and room spinning" for the past two days that are intermittent. Your records indicate a
history of back pain, diabetes and hypertension. Upon further questioning, Mr. Jones cannot
identify when these spells come on and nothing seems to relieve them. His temperature is 98.6
Fahrenheit; blood pressure is 165/95 mmHg; heart rate is 78 beats/minute; and respiratory rate
is 18 breaths/minute. On physical exam, you notice a slight nystagmus. You ask him to focus on
your nose but the nystagmus continues.
What is the most likely cause of his "dizzy spells"?
A. Anemia
B. Bleeding gastric ulcer
C. Hyperthyroidism with thyroid storm
D. Stroke
E. Vestibular neuritis - answer-D.
This patient displays symptoms of vertigo and findings of nystagmus suggesting a neurologic
problem with balance. Thus, anemia (A), bleeding ulcer (B), and thyroid storm (C) - all of which
may present with presyncope (but should not cause vertigo) - are not likely diagnoses. He is
likely suffering from a central lesion (ie: TIA/stroke) causing vertigo. The acute onset of
symptoms, nystagmus that changes direction and nystagmus that does not resolve with gaze
1
, fixation are consistent with a central lesion as opposed to a peripheral lesion. In a peripheral
cause, such as vestibular neuritis (E), one would expect the patient's nystagmus to resolve upon
focusing on your nose.
You are seeing a 54-year-old female with a past medical history of kidney stones who presents
with a chief complaint of "I have a terrible summer cold." She reports three days of low grade
fevers (peak of 100.0 Fahrenheit), cough, sore throat, headaches, and nasal congestion. She
denies myalgias. Her temperature today is 99.2 Fahrenheit, respirations 14/minute, pulse 78
beats/minute, and blood pressure of 128/74 mmHg. Her head and neck exam reveals normal
tympanic membranes, mildly congested nasal turbinates with thin mucous, erythema of the
tonsillar pillars and soft palate without tonsillar enlargement or exudate, and mild anterior
cervical lymphadenopathy. Her lungs are clear to auscultation.
Which of the following options would be the most appropriate therapeutic option for this
patient?
A. Echinacea supplementation
B. Oseltamivir (Tamiflu) 75 mg twice daily for five days
C. Pseudoephedrine (Sudafed) as needed f - answer-C.
This patient has the symptoms and physical exam consistent with the acute infectious
rhinosinusitis (ie. the common cold). Treatments that have been demonstrated to help
symptoms of the common cold include decongestants such as pseudoephedrine (C), nasal
ipratropium spray, and (with weaker evidence supporting it) vitamin C. Vitamin C (D) would be
inappropriate in this patient because it can cause kidney stones, which she has had in the past.
Zinc (E) and echinacea (A) have not been demonstrated to consistently improve symptoms of
the common cold. Oseltamivir (B) is a treatment for influenza, which typically has outbreaks in
the winter and typically causes higher fevers and prominent myalgias.
You are seeing a 60-year-old male brought into your office because of "dizzy spells where he
almost passes out" for a week. Your records indicate a history of back pain and diabetes. Upon
further questioning, he says he sometimes feels like he is going to pass out and gets short of
breath after walking about half a block. He's never felt this way before. He denies having a
spinning sensation when he is dizzy. His back has also been really bothering him for the past
several weeks so he has been taking ibuprofen "all the time." His temperature is 98.6
2
