CASE

Mr. W is a 29-year-old man who arrives at the emergency department with a chief complaint of dizziness. He reports that he was in his usual state of excellent health until about 1 hour ago. At that time he experienced a fairly intense sensation of dizziness. He describes the sensation as spinning. He also complains of a severe headache with neck pain.

Mr. W reports that he has never experienced vertigo before. He has an occasional headache that resolves with ibuprofen and has never been associated with an aura. He has no known vascular disease and does not have a history of hypertension, diabetes, tobacco use, coagulopathy, atrial fibrillation, or cocaine use. He has no known malignancy. Finally, although he feels that it is unrelated, he mentions that he saw a chiropractor for cervical adjustment about 1 hour before his symptoms started. He reports that he sees his chiropractor regularly and has never had any symptoms subsequently.

On exam he looks fairly uncomfortable. His vital signs are normal except for mild hypertension 140/90 mm Hg. His cranial nerve exam and gait are normal. He has no nystagmus or dysmetria. The remainder of his exam is unremarkable.

An emergent head CT without contrast is performed and normal. On reevaluation, Mr. W complains of weakness on his left side. Neurologic exam reveals a new flaccid paralysis on the left side.

An emergent MRA is performed and reveals a VAD with new evidence of thrombosis in the left vertebral artery. Despite anticoagulation, the neurologic deficit progresses. Within 24 hours, a major brainstem infarction occurred resulting in quadriparesis and loss of multiple cranial nerve functions. The patient is unable to speak, look around, or move. He has locked-in syndrome. At follow-up 5 years later, he has not improved and will spend the remainder of his life in a nursing home.

NOTE
S: 29 y/o man c/o dizziness that began approximately one hour ago. At that time he experienced intense dizziness he describes as spinning as well as severe headache and neck pain. He reports seeing a chiropractor for cervical adjustment one hour before onset of symptoms and states that he sees a chiropractor regularly without subsequent symptoms. He has history of occasional headache without aura that resolves with ibuprofen. Denies history of vertigo, known vascular disease or malignancy, hypertension, diabetes, tobacco use, coagulopathy, atrial fibrillation, or cocaine use.

O:

BP 140/90

Physical exam: pt appears uncomfortable, nerve exam and gait are normal, no nystagmus or dysmetria

Head CT w/o contrast: normal

Neurologic exam: flaccid paralysis on left side

MRA: VAD w/ new evidence of thrombus in left vertebral artery

A:VAD w/ thrombosis of left vertebral artery R/O vestibular migraine, cerebellar hemorrhage, intracranial neoplasm

P:treat with anticoagulation therapy and monitor

Evaluation of patients with dizziness is primarily concerned with determining if the patient is experiencing vertigo, disequilibrium, near syncope, or ill-defined lightheadedness. Vertigo is characterized by a spinning sensation or sensation of self motion when none is occurring which typically presents when a patient is turning over in bed or moving the head. The most common chief complaint associated with near syncope a sense of impending loss of consciousness and usually presents while the patient is standing. Disequilibrium is characterized by a lack of stability while seated, standing, or walking and generally presents while the patient is walking. Nonspecific dizziness is described as being floating or vague and typically presents when the patient is feeling stressed. From Mr. W’s description of the onset of dizziness, vertigo is determined to be the cause. Taking into account Mr. W’s young age and overall good health, a differential diagnosis of vestibular migraine is made, but given the fact that Mr. W has never had a migraine prior to this incident and new-onset migraines with vertigo are very unusual other diagnoses are explored.

Given the fact that Mr. W does not have a prior history of headache associated with vertigo a diagnosis of cerebellar hemorrhage is explored as it is imminently life threatening and must be excluded. The normal CT is reassuring as it decreases the likelihood (93% specificity) of a cerebellar hemorrhage. After the neurologic exam revels new flaccid paralysis on the left side a revised leading hypothesis is made of vertebral artery dissection (VAD). VAD generally presents in younger populations and symptoms include severe neck pain, occipital headache, and evolving neurologic symptoms due to progressive involvement of the brainstem. The vertebral artery passes through the transverse process of the cervical vertebrae and as C1 rotates on C2 the artery can be stretched and injured leading to dissection and subsequent thrombosis or aneurysm formation. In the case of Mr. W an emergent MRA was performed and revealed a VAD with evidence of a thrombosis in the left vertebral artery. Even with the indicated anticoagulation therapy a major infarction of the brainstem occurred resulting in locked-in syndrome.

REFLECTION

For my first SOAP note I was assigned the topic of dizziness. As I read through the cases in Symptom to Diagnosis: An Evidence-Based Guide, 3e by Scott D.C. Stern, Adam S. Cifu, Diane Altkorn that related to my assigned topic I learned that there are four categories under which the experience of dizziness can fall: vertigo, disequilibrium, near syncope, or ill-defined lightheadedness. So much of what we have learned this semester has emphasized the importance of taking a thorough and accurate patient history and upon reading the cases in the text I see why. A large part of the diagnosis stems from the history, in the case of dizziness, it was generally the patient history that lead to determining under which category the patient fell and the type of dizziness the patient was experiencing lead to decisions regarding further testing and treatment. This is the first SOAP note I have ever written, and so each step was new to me. I generally consider myself to be a good writer, but medical writing is so different and has definitely proven to be difficult for me. In order to be effective, it has to be direct and to the point and unnecessary words are not helpful. Logically it makes sense to only include data when writing the O (objective) portion of the SOAP note, but I still found myself wanting to add more. I also think that the A (assessment) portion of my note could have been stronger. All of that being said, I do understand that like any skill writing SOAP notes is something that will require practice on my part.