The Room Spins When She Rolls Over: A Focused HEENT, Neurologic, and Mental Health Assessment of a 71-Year-Old Widow
[Student Name]
University of Phoenix
NSG/523: Advanced Health Assessment
Week 3 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. No real patient, clinician or practice is described.
Subjective
The patient is a composite 71-year-old retired school secretary who booked a same-week visit with her nurse practitioner for dizziness. Ten days ago she woke, rolled onto her right side and felt the room spin violently for less than a minute. Since then the spinning has returned several times a day, always when she lies down, rolls to the right in bed, gets up from bed or tilts her head back to reach a high shelf. Each spell lasts under a minute and is followed by mild nausea and a feeling of unsteadiness for a few minutes. Between spells she feels normal, and she has not had a single spell while sitting still or standing without moving her head. She rates the spinning as 8 out of 10 at its worst.
She denies hearing loss, ringing in the ears, ear pain or fullness, double vision, slurred speech, facial numbness, weakness or numbness of the arms or legs, trouble swallowing, headache and loss of consciousness. She has not had a recent cold, head injury or new medicine. She has not fallen but is afraid she will, and she has stopped walking to the library and church because of it.
Past history includes hypertension and osteopenia. Medications are amlodipine 5 mg daily and calcium with vitamin D. She lives alone in a two-story house; her husband of 45 years died eight months ago. She does not smoke and drinks a glass of wine on Sundays.
When asked about mood, she said she has felt "flat" since her husband's death, sleeps poorly and has little appetite, and that staying home because of the dizziness has made it worse.
Objective
Vital signs: temperature 36.5 C, blood pressure 132/78 mm Hg seated and 128/76 mm Hg after three minutes standing, with pulse 74 and 78, so no orthostatic change. Respirations 14, oxygen saturation 98% on room air.
Head and face: normocephalic, no tenderness, symmetric facial movement.
Eyes: pupils 3 mm, equal, with brisk direct and consensual response and normal accommodation; extraocular movements full without diplopia; no spontaneous or gaze-evoked nystagmus in primary or lateral gaze. Visual acuity 20/30 in each eye with her glasses. Fundi show sharp disc margins.
Ears: external canals clear; tympanic membranes pearly gray with normal landmarks bilaterally. She repeated whispered numbers correctly with each ear tested separately. Weber midline and Rinne air conduction greater than bone conduction bilaterally.
Nose, mouth and throat: unremarkable.
Neurologic: alert and oriented; speech fluent without dysarthria. No cranial nerve deficit on testing of II to XII. Full, equal strength in arms and legs, sensation intact to light touch, reflexes 2+ and symmetric. Coordination normal: no dysmetria on finger-nose-finger or on sliding each heel down the opposite shin; rapid alternating movements normal. Romberg negative. Gait steady on a straight line but cautious when she turns her head.
Positional testing: the Dix-Hallpike maneuver to the left produced no symptoms or nystagmus. To the right, after a latency of about five seconds, she reported spinning, and an upbeating, torsional nystagmus with the upper pole beating toward the right ear appeared, peaked and faded within about 20 seconds. On sitting up, a brief reversal of the nystagmus occurred.
Mental health: the PHQ-2 score was 3, so the PHQ-9 was completed, with a total of 11 and a response of zero on the item about thoughts of self-harm. The Mini-Cog was normal, recalling all three words, with a correctly drawn clock.
Assessment
Right posterior canal benign paroxysmal positional vertigo is the leading diagnosis. The clinical practice guideline for this condition defines posterior canal disease by a history of repeated episodes of vertigo with changes in head position and a Dix-Hallpike test that provokes vertigo with a characteristic torsional, upbeating nystagmus after a brief latency, lasting under a minute (Bhattacharyya et al., 2017). Each element appears in the record above.
Stroke is the diagnosis that must not be missed. The HINTS examination, which combines the head impulse test, nystagmus pattern and a test of skew, was developed to separate stroke from peripheral causes in patients with the acute vestibular syndrome, meaning continuous vertigo lasting a day or more with nystagmus at rest (Kattah et al., 2009). This patient does not have that syndrome; her vertigo is brief and triggered, with no nystagmus at rest, so HINTS is not the appropriate tool and could mislead. Her normal cranial nerve and cerebellar examinations and the absence of neurologic symptoms make a central cause unlikely. Vestibular neuritis is unlikely because her symptoms are episodic rather than continuous, and Meniere disease is unlikely without hearing change, tinnitus or ear fullness. Orthostatic hypotension is excluded by her vital signs, and her medications do not explain her symptoms.
The PHQ-2 score of 3 is the usual cut point for a positive screen (Kroenke et al., 2003), and the follow-up PHQ-9 score of 11 falls in the range its developers described as moderate depression (Kroenke et al., 2001). Eight months after her husband's death, persistent low mood, poor sleep and poor appetite may reflect prolonged grief, a major depressive episode or both, and the dizziness has deepened her isolation. The normal Mini-Cog makes cognitive impairment unlikely as a contributor. She is also at increased risk of falls because of positional vertigo, fear of falling, osteopenia and a two-story home.
Plan
The canalith repositioning maneuver for the right posterior canal will be performed in the office, since the guideline recommends it as treatment for posterior canal disease, and the guideline recommends against routinely using vestibular suppressant medicines such as meclizine for this condition (Bhattacharyya et al., 2017). She will be reassessed in one to two weeks, and if symptoms continue, the maneuver will be repeated or she will be referred for vestibular rehabilitation. She will return sooner for new neurologic symptoms, continuous vertigo or hearing loss.
For her mood, the nurse practitioner discussed the PHQ-9 result with her, offered referral to a grief counselor and a follow-up visit in two weeks to reassess, and discussed whether medication might help later. For falls, she received guidance on getting up slowly, a night light and a referral for a home safety evaluation.
Explaining the Findings to the Patient
The patient's fear shaped how the findings were explained. She had assumed the spinning meant a stroke was coming, which is part of why she stopped going out. The nurse practitioner explained, using a simple drawing of the inner ear, that tiny crystals in one balance canal had moved out of place, that the test had reproduced her symptoms in the way this condition does and that her brain and nerve examination was normal. She was told that the treatment maneuver works for most people within one or two sessions and that some unsteadiness can last a few days afterward. Hearing that her symptoms had a benign, fixable cause visibly relieved her, and she agreed to the counseling referral more readily once the fear of stroke was gone.
Conclusion
A single complaint of dizziness required an assessment across the ears, the nervous system and the mind. The timing and trigger in the history, a precise positional test and a normal neurologic examination support benign positional vertigo and make stroke unlikely, while a validated screen revealed moderate depressive symptoms that were keeping her at home. Treating both is what will return her to the library and church.
References
Bhattacharyya, N., Gubbels, S. P., Schwartz, S. R., Edlow, J. A., El-Kashlan, H., Fife, T., Holmberg, J. M., Mahoney, K., Hollingsworth, D. B., Roberts, R., Seidman, M. D., Steiner, R. W. P., Do, B. T., Voelker, C. C. J., Waguespack, R. W., & Corrigan, M. D. (2017). Clinical practice guideline: Benign paroxysmal positional vertigo (update). Otolaryngology-Head and Neck Surgery, 156(3 Suppl.), S1-S47. https://doi.org/10.1177/0194599816689667
Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504-3510. https://doi.org/10.1161/STROKEAHA.109.551234
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2003). The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284-1292. https://doi.org/10.1097/01.MLR.0000093487.78664.3C
How this NSG 523 Week 3 example is structured
The University of Phoenix library guide for NSG/523 lists Week 3 as HEENT, Neurologic, and Mental Health Assessments. The write-up uses one complaint that crosses all three territories, because dizziness can come from the ear, the brain or the mind, and the examination must decide among them. The history sorts the dizziness by timing and trigger before any test, the examination records the findings that rule out the dangerous causes, and the mental health screen is treated as part of the assessment rather than an afterthought. Students search this week as NSG 523 Week 3, NSG523 Wk 3 or NSG/523 Wk 3; all three are the same assignment.
NSG/523 Week 3 questions, answered
What does NSG/523 Week 3 usually ask for?
The University of Phoenix library guide for NSG/523 lists Week 3 as HEENT, neurologic and mental health assessments. Many sections ask for a focused history and examination write-up on a complaint in those systems, sometimes with a standardized screening tool, and a supported differential. Your instructions decide the exact form.
Why does the timing of dizziness matter so much?
Because timing and triggers sort dizziness into patterns with different causes. Brief spells triggered by head position suggest benign positional vertigo; continuous vertigo lasting days suggests vestibular neuritis or stroke; episodes lasting hours with hearing change suggest Meniere disease. The examination that follows depends on the pattern.
Why include a depression screen in a dizziness write-up?
Mental health is part of this week's assessment, and older adults with dizziness often limit activity, become isolated and develop low mood or fear of falling. A brief validated screen such as the PHQ-2 followed by the PHQ-9 finds problems that the patient may not mention.
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