Headache and dizziness in a 54-year-old man

Physical Examination

  • General appearance: Height, 175 cm, weight 69 kg. Normal appearing male appears younger than stated age, in no apparent distress.

  • Vital signs:
  • Temperature: 37.0° C
  • Pulse: 71 beats/min
  • BP: 120/70 mm Hg
  • Respirations: 12/min

  • Skin: No skin lesions, ecchymoses, or petechiae. No café-au-lait spots noted.

  • HEENT: Extraocular movements normal, no nystagmus, no ptosis. Ears: pinnae mobile and pain-free. External auditory canals and tympanic membrane normal. Tuning fork (Weber) testing lateralizes to left ear; mastoid bone conduction (Rinne) demonstrates bone conduction superior to air conduction on right side. Neck supple, no discomfort with active or passive flexion.

  • Pulmonary: Lungs clear, normal chest movement, no wheezes, rales, or rhonchi.

  • Cardiovascular: Regular rhythm, S1 and S2 normal, no murmurs, rubs, or gallops.

  • Gastrointestinal: Abdomen soft, nontender; normal bowel sounds; no palpable organs or masses.

  • Genitourinary: Noncontributory

  • Musculoskeletal: Mild tenderness to firm palpation over L-S spine, otherwise normal.

  • Neurologic: No facial pain or parasthesias, no apparent drooping of facial muscles. Patient is able to raise eyebrows symmetrically, close eyes, smile, show teeth, puff out cheeks. No nystagmus. No response to caloric stimuli in right ear, left ear normal. When asked to stand with eyes closed and feet together, the patient sways but does not fall. Strength and sensation in all extremities normal, Babinski sign normal. Gait is unsteady.

  • Mental status: Alert, oriented to person, place, and time. He responds clearly and coherently to questions and commands.