Internal Medicine History and Physical
Pierce, Brittany
DOB: 04/11/1962
MRN: 5689234018
Chief Complaint: “Dizziness”
History of Chief Complaint: 49 year-old white female presenting with 3 days of persistent
dizziness, described as the sensation the room is spinning. It started after she awoke three days ago
with a pounding headache on her right side that was associated with nausea but no vomiting, and
sensitivity to light and sound. The headache resolved after about 2 hours, but the dizziness persisted
and has not gotten any better or worse despite trying over-the-counter Sudafed and Benadryl. The
dizziness does not vary with position and she has an associated sense of “fullness” in her right ear,
and hearing in her right ear is muffled. Denies frank pain in ears, ear discharge, changes in vision or
speech, trauma, or previous similar episodes. No recent illnesses, travel or sick contacts.
Past Medical History:
Hypertension
Seasonal allergies
Surgeries:
Total vaginal hysterectomy 2 years ago
Medications:
Lisinopril-HCTZ 20/12.5 mg daily
Benadryl OTC as needed
Review of Systems:
General: Denies increased fatigue, weight
gain or loss, sleeplessness or insomnia.
HEENT: See HxCC. Otherwise denies
headaches, blurry or double vision, changes in
vision or senses of smell or taste.
Respiratory: Denies trouble breathing,
shortness of breath, or cough.
Cardiovascular: Denies chest pain,
palpitations, irregular or rapid heartbeats.
Gastrointestinal: Occasional constipation
which she treats with prune juice. Denies
diarrhea, constipation, blood in stool, or
black, tarry stools.
Vitals:
Allergies: NKDA
Social History:.
High school math teacher
Nonsmoker, denies alcohol and illicit drug use
No sick contacts and denies any recent travel
Family History:
Mother has a benign brain tumor; never had
surgery, radiation, or chemotherapy. Father
has hypertension and hyperlipidemia.
Genitourinary: Denies dysuria, changes in
urinary habits or frequency.
Musculoskeletal: Denies joint or back pain,
weak muscles or increased pain with
movement.
Neurologic: Denies diplopia, dysarthria,
dysphagia or ataxia.
Hematological: Denies bleeding, easy
bruising, or wounds that won’t heal.
Integumentary: Denies any rashes,
petechiae, ecchymoses, or abnormal lesions.
Psychiatric: Denies depression, anxiety,
suicidal or homicidal thoughts.
T: 98.1 P: 70 R: 14 BP: 127/76 PO: 100% on RA Pain: 0/10
Physical Exam:
General Appearance: Appears stated age; in
no acute distress. Alert and communicating
appropriately.
Head: Symmetrical, normocephalic without
palpable masses.
Eyes: Conjunctiva and sclera non-injected,
non-icteric. Extraocular muscles (EOM)
intact without ptosis or exophthalmus. No
nystagmus with Dix-Hallpike maneuver.
Pupils equal, react to light and
accommodation (PERLA).
Ears: External auditory canals patent,
tympanic membranes clear, bony landmarks
visualized.
Nose: Mucosa pink, moist without
deformities, bleeding or discharge.
Throat/Mouth: Lips pink, tongue pink
without atrophy. Buccal mucosa, palate, and
uvula pink and moist without lesion or
masses. Tonsils absent. Teeth are in good
repair .
Neck: Supple without nuchal rigidity. No
jugular vein distention. Carotid pulses are
equal bilaterally without bruits. Thyroid not
enlarged, moves with swallowing. Trachea
midline.
Lymphatic: No enlargement or tenderness of
cervical, axillary, or inguinal lymph nodes.
Lungs: Clear to auscultation (CTA) without
rhonchi, rales, wheezes, crackles, or impaired
resonance in all fields with adquate aeration
throughout.
Heart: Regular rate and rhythm (RRR) with
S1 equal to S2. No murmurs, gallops or rubs.
PMI approximates 5th intercostal space
midclavicular line, left without pulsations,
thrills or heaves.
Abdomen: Soft, nontender, nondistended.
No palpable masses or organomegaly.
Normal bowel sounds present.
Genitourinary: Perianal area intact without
lesion, rashes, inflammation, scars. Anal
surface intact without lesion, fissure, fistula,
hemorrhoids. Good sphincter tone.
Extremities: Warm, pink, non-tender with
peripheral pulses: radial, posterior tibial, and
dorsalis pedis +2/4 equal bilaterally. No
edema, varicosities, lesions, deformities.
Capillary refill 2-3 seconds bilaterally. Muscle
mass symmetrical bilaterally with full active,
passive range of motion (ROM).
Neurological: Cranial nerves II-XII intact
bilaterally. Oriented to person, place and time
(Ox3). Reflexes are +2/4 and equal
bilaterally for patellar, Achilles, biceps, triceps.
Babinski reflex is down-going bilaterally.
Structural Exam: Shoulders, iliac crest
height are level. No apparent abnormality of
kyphotic or lordotic curves. No scoliosis.
Paravertebral musculature is symmetrical and
non-tender with palpation.
Skin: No erythema, redness, rashes, or
lesions. No unusual dryness or irritation.
Labs/Imaging:
14.2
141
102
15
104
400
8.2
3.7
26
0.8
39.1
Assessment: 49 year-old white female with PMH of HTN and seasonal allergies presenting with a
3-day history of vertigo accompanied by hearing impairment and sensation of fullness in right ear
that began after the onset of a pounding, unilateral headache with photo/phonophobia and nausea
but no vomiting. The headache resolved after 2 hours, but the vertigo persisted. No recent
illnesses, Dix-Hallpike negative, family history of brain tumor in mother (unknown type).
Plan:
 Differential: Meniere’s disease, vestibular neuronitis, perilymphatic fistula,
brainstem/cerebellar stroke, subarachnoid hemorrhage
 Noncontrast head CT
 Lumbar puncture?