359.A 67-year-old man is brought to the ED by his wife who states that
her husband’s face looks different and that he has been nauseated, vomiting,
and unsteady on his feet since yesterday. The patient also states that he has
been having blurry vision and difficulty swallowing, in addition to feeling
like the room is tilting from side to side. The patient attributes this to eating
leftover salmon last night. The patient’s past medical history is notable for
obesity and hypertension. His BP is 187/89 mm Hg, HR is 86 beats per minute,
temperature is 99.3°F, and RR is 13 breaths per minute. On examination, you
find a right facial droop, diplopia, vertical nystagmus, and severe ataxia. Which
of the following is the most likely diagnosis?
a. Lacunar infarct
b. BPV
c. Labyrinthitis
d. Posterior cerebral artery occlusion
e. Vertebrobasilar artery occlusion
360.A 45-year-old man presents to the ED complaining of recurrent episodes
of lightheadedness and nausea overnight. He describes the episodes as a room
swaying from side-to-side when he lies on his left side. He reports mild
headache now and denies tinnitus, hearing loss, fevers, or vomiting. He has
no medical problems and takes no medications except for occasional aceta-
minophen. His BP is 123/65 mm Hg, HR is 69 beats per minute, temperature
is 98.5°F, and RR is 12 breaths per minute. The patient is asymptomatic
now and the examination is unremarkable. Which of the following is the
most appropriate diagnostic test?
a. Dix-Hallpike maneuver
b. Caloric stimulation testing
c. Orthostatic vital signs
d. Head CT scan
e. ECG
380 Emergency Medicine