Solve the Medical Riddle: She Constantly Feels as Though She’s Swaying and Rocking, First Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told the doctor and how the doctor proceeded with the examination. Next week, the doctor will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient’s Reports Her Symptoms

Judy, a 53-year-old high school English teacher, presented with the constant sensation that she was swaying and rocking.
Her doctor used the classic S-O-A-P notes as follows:
S=Symptoms or Chief Complaint
O=Objective Findings
A=Assessment or Analysis
P=Treatment Plan or Recommendations

This week, we’ll cover S, Symptoms or Chief Complaint. Here’s what Sally told the doctor:

“For about two years, I’ve had the constant feeling that I’m swaying and rocking. I also have ‘brain fog’, I’m exhausted all the time, I don’t sleep soundly, and I have frequent headaches. I’ve missed many days of work because I just haven’t felt well enough to deal with classrooms full of teenagers. I kept telling myself this would pass when I got through menopause but I had my last period a year ago and I’m still feeling terrible.

“The weird thing is that when I’m in the car, whether driving or riding, the swaying sensation stops. But then it comes right back when I get out of the car and I’m always afraid of falling. I hope you can help because this problem is making my life miserable!”

After hearing Judy’s complaint, the doctor suspected that it could be vestibular in origin. The vestibular system, including the cochlea and vestibule. of the inner ear, is the sensory system that contributes to balance and spatial orientation. The doctor proceeded with a thorough evaluation for a differential diagnosis, which in laymen’s language simply mean eliminating possible conditions or causes.

The PCP started the evaluation process, but she let Judy know that she would give her a referral for an MRI to rule out right away the remote but potentially serious possibility of a brain tumor, and that she would also give Judy a referral either to a neurologist or an otolaryngologist (Ear, Nose Throat specialist, ENT) depending on thoughts and concerns after the initial examination.

First, the doctor asked Judy to describe in as much detail as possible what she recalled about the onset of the problem. What was going on about two years ago when it all started? Judy had not kept a “health journal”, always a good idea when dealing with new symptoms, so she had to rely on her memory. Here’s what she came up with at the first visit:

Perimenopause and menopause: “When I was in my late 40s, my periods got very irregular and heavy and then I had my last period a year ago when I was 52.”

Hormone Replacement Therapy“I had pretty bad hot flashes and night sweats, so the doctor I was seeing before we switched insurance plans and I started seeing you put me on a transdermal patch and oral progesterone for HRT. That did help.”

An Empty Nest”Our second child left for college right after my 51st birthday. I was surprised how weepy and lonely that made me. I would go to the supermarket and tear up in the cereal aisle when I realized I didn’t have to buy the Raisin Bran for the kids any longer. My husband kept saying it was great to be just the two of us and he never really understood how empty I felt. Also, he wanted sex more often but I was finding it painful. Just the effects of aging I guess. It wasn’t a very good time in my life.”

30th Anniversary Cruise”However, our 30th anniversary was coming up and my husband convinced me that we should celebrate by going on our first ever cruise. It was a fantastic two weeks and it actually did cheer me up and make me realize that this new chapter of my life can be a positive one – that is, if I could get rid of whatever is making me feel so bad!”

The doctor then did a Review of Symptoms (ROS), systematically going head to toe asking about symptoms including whether Judy was experiencing other vestibular or brain stem issues including:
• hearing loss
• tinnitus (ringing in ears)
• tingling
• weakness
• clumsiness
• balance issues
• postural changes to symptoms such as when she gets up quickly from lying position
• a prolonged upper respiratory infection or sinus infection that could cause labyrinthitis, an ear disorder that involves irritation and swelling of the inner ear.
• vomiting
• cold sweats
• double vision or bouncing vision
• trauma or head injury in the past

Judy said she did not have any of those problems. The doctor asked Judy to make an appointment for the following week and to let the receptionist know she would need a complete physical. That way, sufficient time would be scheduled so that a comprehensive work-up could be done.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the doctor moved on to O, Objective Findings and A=Assessment or Analysis, in her quest for a correct diagnosis of Judy’s complaint . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Pleas visit DrSavard.com.