DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTANT: Jane Doe, MD
REASON FOR CONSULTATION: Acute dizziness.
IMPRESSION:
1. Acute exacerbation of chronic benign positional vertigo.
2. Underlying complex medical history including acute exacerbation of chronic obstructive pulmonary disease, depression, diabetes, and hypertension.
3. No evidence of external or middle ear disease.
4. History of presbyacusis exacerbating above.
RECOMMENDATIONS:
1. Physical therapy evaluation for vestibular evaluation and possible rehabilitation.
2. Vestibular testing can be performed, but it is generally performed in the office as an outpatient. We recommend that the patient be followed up once she is discharged and sent back to her extended care facility.
CHIEF COMPLAINT AND HISTORY: This is an (XX)-year-old female seen in consultation, who presents with history of increasing shortness of breath. She has a history of chronic respiratory failure, pulmonary fibrosis, and COPD. Also, of note, over the last several days, she has had intermittent episodes of acute spinning-type vertigo. She notes this is typically 2-3 o'clock in the morning when in bed. She denies any daytime dizziness and notes that she is fairly stable otherwise. She denies any change in her hearing; although, she has a history of hearing loss. She denies any tinnitus. There has been no otalgia and no drainage posteriorly and no drainage in the ears.
PAST MEDICAL HISTORY: As noted.
PAST SURGICAL HISTORY: Reviewed at length in the chart.
LABORATORY DATA: The data is reviewed and this is relatively normal, except for elevated glucose.
PHYSICAL EXAMINATION:
GENERAL: On examination today, she is sleeping quietly but is easily awakened.
VITAL SIGNS: Pulse 86, blood pressure 134/74, and respirations 22.
HEENT: The head is normocephalic. Trachea is in the midline. Both ears, including auricles, external auditory canal and tympanic membranes are all intact. The middle ear shows no effusion or retraction. Nose externally is in the midline and internally shows mild septal deviation. Oropharynx shows upper and lower plates. She has had a tonsillectomy. She has an intact gag reflex. Tongue protrudes in the midline. There are no ulcerations or lesions present.
NECK: No lymphadenopathy.
HEART: Regular rate and rhythm.
LUNGS: Lung sounds are distant and shallow.
At this point, the patient appears to have had an acute exacerbation of her chronic benign positional vertigo. She does not appear to have had any distinct treatment for this. As such, physical therapy including Cawthorne and Brandt-Daroff exercises can generally clear this for the most part. We recommend physical therapy evaluate them for this. If she has continued disequilibrium, then certainly vestibular testing should be performed and this could be done in my office.
Thank you for the opportunity to participate in the care of your patient.
