Question of the Week # 308

308)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most likely explanation for his Vertigo?

A) Orthostatic Hypotension

B) Vertebral artery occlusion from cervical spondylosis

C) Cerumen Impaction

D) Meniere’s disease

E) Labyrinthitis

Question of the Week # 307

307) A 35 year old woman is evaluated in your office during an antenatal visit. Her last menstrual period was 8 weeks ago. She tells you that 2 weeks after she missed her regular menstrual period she checked herself with home pregnancy kit and tested positive. She works in a day-care center. She is concerned now because she received Rubella vaccination 4 weeks ago after an exposure to a sick child without knowing that she was pregnant. She read about the dangers to fetus on the internet and is very worried. Physical examination is benign.

Which of the following is the most appropriate course of action?

A. Refer her to medical termination of pregnancy
B. Tell her that there is a high established risk to fetus and she should strongly consider termination of pregnancy
C. Counsel her about theoretical risk to fetus and continue pregnancy care
D. Administer Rubella immunoglobulin
E. Reassure her that there is no risk to fetus.

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