REASON CHIEF COMPLAINT: Trouble with balance. BLANKLINE In early September, he had an episode where he got severely vertiginous, spinning around and was nauseated. He felt like he was going to pass out. Now he continues to have trouble with his balance. When he looks at things they seem to jerk to the left. It feels like there was something in his ears. Currently, he is able to get around with a cane and as long as he has a point of reference his balance is fair. He can take meclizine which has been of help to him. He also has trouble with nasal congestion that has been controlled with the use of fluticasone. He has trouble with urinary retention because of prostate enlargement. He was told that he should take Flomax, but wanted to be sure it was okay with his dizziness problem. PHYSICAL EXAMINATION Ears: There was wax in both ears, which was removed. Following removal of the wax, both tympanic membranes were pearly gray without any evidence of fluid. Nose: Septum is straight. Mouth: Oral cavity, dentures are good. No lesions …show more content…
I think he had a severe episode of labyrinthitis and the residual balance disturbances from that. MRI is pending with the results which the MRI was done about two weeks ago, but the results so far have not been available. I would continue the use of meclizine as needed. 2. He has nasal congestion that has helped with Flonase. He should continue with the Flonase. 3. He has urinary frequency from prostate hypertrophy. It is okay for him to use Flonase. This will not cause any problems with his labyrinthitis, which is recovering. This is a bit unusual to have this much symptoms two months after an acute labyrinthitis. If he does not continue improving over the next couple of months, he should be evaluated again. His MRI is pending and it will be important to have the results of that. If he continues to have problems, he should be referred to audiology for some specific balance