The Nervous System

Conditions involving the nervous system can present in many different ways.

Dizziness is a common complaint and can have many causes for medics to sort through, some of which may be linked to the central nervous system, peripheral nervous system, endocrine system, cardiovascular and respiratory systems, infection, brain tumors or toxicologic and behavioral problems. Sometimes, the causes remain unknown.1 A thorough history and systems survey must be done to eliminate as many possibilities as possible.

Case Scenario

Barbara, a 51-year-old female, calls 9-1-1 because she has become extremely dizzy.2 Barbara started smoking when she was 16, smokes two packs per day and drinks alcohol socially. She has had no significant previous illnesses. She does suffer from allergies to dust and pollen and has frequent sinus problems. She is not diabetic and has never had this problem before. She takes over-the-counter allergy drugs and denies any drug or food allergies.

History of the Present Illness

Present history must be carefully elicited to avoid closed-ended questions and “putting words into the patient’s mouth.” Ask the patient to describe her symptoms without using the word “dizzy.”3

Barbara says she awoke and got out of bed this morning only to sense the room “spinning around” her. She quickly got back into bed and the spinning stopped, but each time she got up, the same thing happened again. She tried to get to the bathroom and almost fell, finally opting to crawl on her hands and knees to keep from falling. She was nauseous and vomited violently. Now she is lying on the sofa in the living room. She says that every time she moves she feels the spinning and feels like vomiting.

She describes her symptoms as feeling “like the room is turning over and over and spinning around,” and “I’m fine when I’m not moving, but the minute I move, the spinning starts again.” She denies having fever, chills, weight loss, night sweats, or having been bitten or stung. She denies chest pain or abdominal pain.

This history is highly suggestive of vertigo, a condition involving the inner ear. Vertigo may be peripheral or central in etiology, or caused by problems in one of the systems mentioned above.4

Peripheral vertigo can be one of the following:

  • Benign paroxysmal positional vertigo (BPPV), caused by dislodged calcium deposits in the inner ear that move with positional changes and cause a feeling of motion. Onset is sudden and often occurs when arising or rolling over in bed.
  • Vestibular neuronitis (acute labyrinthitis) starts gradually and reaches a climax in 24–48 hours, sometimes causing nausea and vomiting.
  • Labyrinthine hydrops (Meniere’s disease), characterized by sudden attacks of vertigo with hearing loss in the affected ear, ringing in the ears (tinnitus) and a feeling of fullness in the ear.
  • A result of toxic causes, including drug effects and particularly ethanol (ETOH).5

Central vertigo is due to a central lesion in the brain involving cranial nerve VIII; the auditory nerve; brain tumors, cerebral hemorrhage or infarction; infection such as meningitis; and arterial-venous malformations.6

Physical Exam

Barbara appears to be a well-groomed female of her stated age, weighing approximately 165 pounds. Lying on a sofa, she is alert and answers questions appropriately.

Vital signs: BP 142/88, HR 84 and regular, RR 16 breaths per minute, temperature 99.4 Fº, blood glucose 85, pulse oximetry 99% on room air. Her skin is pink, warm and dry with no rashes. Capillary refill is less than 2 seconds in her fingers.

HEENT: She is normocephalic and atraumatic. Her face is symmetrical and there is no facial droop. Pupils are round and equal at 5 mm and react briskly to light directly and by accommodation. Conjunctiva are pink. Ears are normal looking and without discharge. Nose is stable and without discharge. She is able to hear whispers in each ear. She denies tinnitus or a “full feeling” in her ear. Oral mucosa are pink; tongue is pink and she moves it in all directions on command; uvula is in the midline. She is able to repeat “no ifs, ands or buts,” without slurring. Pharynx is slightly red but without exudates.

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