let's play the diagnosis game

1.            you have a 50-year-old man with ringing in his ears and he feels the room spinning around him. he also tells you his hearing in his left ear has slowly gotten worse. he says that this all began a while ago, along with a slight feeling of unsteadiness. he has no chronic medical conditions and does not take any medications. examination shows nystagmus. what is the most likely diagnosis?

Dx: meniere's disease, which is characterized by tinnitus, vertigo, and progressive hearing loss (his hearing got worse slowly). it is thought to be related to a degeneration of the vestibular and cochlear hair cells. treatment includes bed rest, a low-salt diet, dimenhydrinate, cyclizine or meclizine. 

perhaps you considered it being benign positional vertigo, but recall that, BPV is characterized by paroxysmal vertigo and nystagmus. it is brought on by certain changes in position and hearing loss is not present. therefor, you can rule it out of the differential.

2.            an 18-year-old male student is admitted for psychosis. he is put in seclusion because he is highly aggressive and a threat to others. he was given haloperidol intramuscularly twice so far. suddenly, he has acute torticollis and twitching of the mouth and face on that side. what reaction did this patient most likely have?

acute dystonia, an involuntary spasm of a particular group of muscles that can involve the neck, jaw, tongue, eyes, or the entire body. it can be an early adverse effect of antipsychotics, and it is more common in younger men. it is more common with typical antipsychotics. the treatment of choice is parenteral administration of anticholinergics.

 3.            a 15-year-old, obese boy complains of persistent knee pain for several weeks and came into your office, limping. he sits in the examining table with the sole of the foot on the affected side pointing to the other leg. however, physical examination is normal for the knee, but shows limited hip motion. when the hip is flexed, the leg goes into external rotation and cannot be rotated internally. which of the following is the most likely diagnosis: avascular necrosis of the femoral head OR slipped capital femoral epiphysis?

slipped capital femoral epiphysis, an orthopedic emergency. it has a classic clinical picture: a chubby male, early teens, who is limping and cannot rotate his leg internally. also, this hip pathology will produce knee pain, but the knee is normal on physical examination.

avascular necrosis is seen in younger children, around 6 years of age.