Student’s Name: Aaliyah Elmore__________________
MSN 620 Case Study: David Brooks, a 52-Year-Old Male with Vertigo and Nausea
Patient Presentation:
David Brooks, a 52-year-old male, presents to the clinic complaining of intermittent episodes of
dizziness and nausea that began approximately five days ago. He describes the dizziness as a
sensation that the room is spinning, which worsens when he turns his head quickly or bends
forward. He also reports a feeling of pressure around his forehead and eyes, nasal congestion,
and mild post-nasal drip that began about a week ago and seems to coincide with the onset of
dizziness. The nausea is mild and occurs during dizzy episodes. He denies vomiting, tinnitus,
hearing loss, or ear pain. He reports a mild headache and facial discomfort but attributes it to
sinus pressure. Denies fevers or recent travel. He states he had a “bad cold” a week ago but
thought it was improving. This is the first time he’s experienced vertigo.
Medical History:
Allergic rhinitis
Mild hypertension (well-controlled)
No history of ear infections or vertigo
No recent trauma
No prior surgeries
Non-smoker, drinks 1–2 alcoholic beverages/week
Allergies: PCN
Current Medications:
Lisinopril 10 mg PO daily
Loratadine 10 mg PO daily (as needed during allergy season)
Occasional ibuprofen for headaches
Vital Signs:
BP: 124/78 mmHg
HR: 76 bpm
RR: 16 bpm
Temp: 98.9°F (37.2°C)
O2 Sat: 98% on room air
Physical Examination:
General: Alert and oriented, mild discomfort, no distress
Skin:
Warm, dry, and intact
No rashes
Head, Eyes, Ears, Nose, Throat (HEENT):
Head:
Normocephalic, atraumatic
No scalp tenderness or masses
Frontal and maxillary sinuses tender to palpation
, Eyes:
Pupils equal, round, reactive to light and accommodation (PERRLA)
Extraocular movements intact (EOMI)
No nystagmus at rest or with gaze testing
Fundoscopic exam: no papilledema or retinal abnormalities
Visual acuity grossly intact
Ears:
External ear canals clear bilaterally
Tympanic membranes intact, normal light reflexes, no bulging or erythema
No fluid levels or retraction noted
No mastoid tenderness
Nose:
Mucosa erythematous and edematous bilaterally
Thick yellow mucoid discharge present
Mild septal deviation to the right
No nasal polyps or foreign bodies
Throat:
Mild posterior pharyngeal erythema, post-nasal drip noted
Tonsils not enlarged, no exudate
Uvula midline
No oral ulcers or lesions
Neck:
Supple, full range of motion
No cervical lymphadenopathy
No thyromegaly
Respiratory:
Chest symmetric, no retractions or accessory muscle use
Lungs clear to auscultation bilaterally
No wheezes, rales, or rhonchi
Normal respiratory effort
Cardiovascular:
Regular rate and rhythm
S1 and S2 present, no murmurs, gallops, or rubs
No jugular venous distention
Neurologic:
No facial asymmetry, dysarthria, or dysphagia
Cerebellar/Balance:
Negative Romberg sign
Mild unsteadiness noted with rapid head turns to the left
Finger-to-nose and heel-to-shin testing intact
Gait steady but cautious; no ataxia
Sensory and Motor:
Normal strength and tone in all extremities
Sensation intact to light touch and pinprick
Deep tendon reflexes 2+ and symmetric
MSN 620 Case Study: David Brooks, a 52-Year-Old Male with Vertigo and Nausea
Patient Presentation:
David Brooks, a 52-year-old male, presents to the clinic complaining of intermittent episodes of
dizziness and nausea that began approximately five days ago. He describes the dizziness as a
sensation that the room is spinning, which worsens when he turns his head quickly or bends
forward. He also reports a feeling of pressure around his forehead and eyes, nasal congestion,
and mild post-nasal drip that began about a week ago and seems to coincide with the onset of
dizziness. The nausea is mild and occurs during dizzy episodes. He denies vomiting, tinnitus,
hearing loss, or ear pain. He reports a mild headache and facial discomfort but attributes it to
sinus pressure. Denies fevers or recent travel. He states he had a “bad cold” a week ago but
thought it was improving. This is the first time he’s experienced vertigo.
Medical History:
Allergic rhinitis
Mild hypertension (well-controlled)
No history of ear infections or vertigo
No recent trauma
No prior surgeries
Non-smoker, drinks 1–2 alcoholic beverages/week
Allergies: PCN
Current Medications:
Lisinopril 10 mg PO daily
Loratadine 10 mg PO daily (as needed during allergy season)
Occasional ibuprofen for headaches
Vital Signs:
BP: 124/78 mmHg
HR: 76 bpm
RR: 16 bpm
Temp: 98.9°F (37.2°C)
O2 Sat: 98% on room air
Physical Examination:
General: Alert and oriented, mild discomfort, no distress
Skin:
Warm, dry, and intact
No rashes
Head, Eyes, Ears, Nose, Throat (HEENT):
Head:
Normocephalic, atraumatic
No scalp tenderness or masses
Frontal and maxillary sinuses tender to palpation
, Eyes:
Pupils equal, round, reactive to light and accommodation (PERRLA)
Extraocular movements intact (EOMI)
No nystagmus at rest or with gaze testing
Fundoscopic exam: no papilledema or retinal abnormalities
Visual acuity grossly intact
Ears:
External ear canals clear bilaterally
Tympanic membranes intact, normal light reflexes, no bulging or erythema
No fluid levels or retraction noted
No mastoid tenderness
Nose:
Mucosa erythematous and edematous bilaterally
Thick yellow mucoid discharge present
Mild septal deviation to the right
No nasal polyps or foreign bodies
Throat:
Mild posterior pharyngeal erythema, post-nasal drip noted
Tonsils not enlarged, no exudate
Uvula midline
No oral ulcers or lesions
Neck:
Supple, full range of motion
No cervical lymphadenopathy
No thyromegaly
Respiratory:
Chest symmetric, no retractions or accessory muscle use
Lungs clear to auscultation bilaterally
No wheezes, rales, or rhonchi
Normal respiratory effort
Cardiovascular:
Regular rate and rhythm
S1 and S2 present, no murmurs, gallops, or rubs
No jugular venous distention
Neurologic:
No facial asymmetry, dysarthria, or dysphagia
Cerebellar/Balance:
Negative Romberg sign
Mild unsteadiness noted with rapid head turns to the left
Finger-to-nose and heel-to-shin testing intact
Gait steady but cautious; no ataxia
Sensory and Motor:
Normal strength and tone in all extremities
Sensation intact to light touch and pinprick
Deep tendon reflexes 2+ and symmetric
