We would like to introduce a new member benefit- the Clinical Case Challenge! Every quarter, a clinical case will be presented. If you think you know the diagnosis, you simply email Membership@pspa.net. Every individual who gets it right will be entered in to a raffle for $25 of Keystone Cash! The next issue of PSPA News will feature the answer, the winner and the next Challenge. You can also win big by submitting your own Clinical Case Challenge. If your case is chosen you can also win $25 of Keystone Cash.
CASE #1: A 36yo Black Male presents with a chief complaint of sore throat. He reports a sore throat for the past 4 days and low grade fever. Denies nasal symptoms, cough, nausea, vomiting or diarrhea. He is not a smoker, and no chronic health concerns, though it’s been about 2 years since his last physical. He reports dizziness as well. On further questioning, he reports intermittent dizziness and “balance problems” for the past 6 months. He reports an occasional “falling” sensation, though he can recall no inciting factors when these episodes occur. They are usually brief, but will occur several times over several days then abate for several weeks or months. He has not discussed this with his PCP.
On exam, well developed, well-nourished male in no acute distress. Vitals: BP 136/80, P 90, T 100.1F, R 16, Ht 70”, Wt 185lbs. Heart: regular rate and rhythm without murmurs, Lungs: clear to auscultation bilaterally without adventitious sounds. HEENT: Normocephalic, ears clear/TMs intact, PERRLA, EOMI, Funduscopic exam- no papilledema, neck supple with some tender anterior cervical lymphadenopathy, mucous membranes moist, pharynx injected, tonsils 2+ erythematous and with exudate. Muscle strength 5/5 and symmetric in upper and lower extremities. On neuro exam, patient is able to do finger-to-nose touching, rapid alternating movements and shin scratch tests symmetrically. DTRs 2+ and symmetric. There is no pronator drift; patient can change position without difficulty. However, he is unable to heel-toe walk or balance on either foot individually. When attempting Romberg test, he has problems keeping his balance after initially closing his eyes but then passes the remainder of the test.
CBC: WBC count- 11.5, H/H- 15.5/45, Platelet- 175, Seg- 85%, Lymph-10%, remainder of count unremarkable
BMP: All within normal limits
Rapid strep test Positive
Patient was treated with Amoxicillin 500mg TID x 10 days and referred for an MRI and to neurology for his dizziness and balance problems. What is the source of the dizziness and balance problems?
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