Differential Diagnosis
The patient presents with a 2-week history of nausea, dizziness, and mild headaches, along with a positive Dix-Hallpike test result and tenderness in the suboccipital region and right upper cervical muscles. Based on the symptoms and physical examination findings, the differential diagnosis can be categorized as follows:
- Single most likely diagnosis
- Benign Paroxysmal Positional Vertigo (BPPV): The positive Dix-Hallpike test result is a strong indicator of BPPV, which is characterized by brief, episodic vertigo triggered by specific head movements. The patient's symptoms of dizziness and feeling off balance while standing or turning his head are also consistent with BPPV.
- Other Likely diagnoses
- Cervicogenic dizziness: The patient's tenderness and hypertonicity in the suboccipital region and right upper cervical muscles suggest a possible cervical origin of his dizziness.
- Vestibular migraine: Although the patient denies visual changes or room-spinning sensations, vestibular migraine can present with a range of symptoms, including dizziness and headaches.
- Anxiety-related dizziness: The patient's history of generalized anxiety disorder and recent stress at work could contribute to his symptoms of dizziness and nausea.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Posterior circulation stroke: Although the patient's physical examination does not suggest a stroke, it is essential to consider this possibility, especially given his age and history of hypertension.
- Vertebral artery dissection: The patient's neck pain and dizziness could be indicative of a vertebral artery dissection, which is a medical emergency.
- Multiple sclerosis: Although less likely, multiple sclerosis can present with a range of symptoms, including dizziness, headaches, and neck pain.
- Rare diagnoses
- Meniere's disease: This inner ear disorder can cause vertigo, tinnitus, and hearing loss, but it is less likely given the patient's lack of auditory symptoms.
- Otosclerosis: This condition can cause vertigo and hearing loss, but it is relatively rare and would not explain the patient's neck pain and tenderness.
The most appropriate next step in the management of this patient would be to perform the canalith repositioning maneuver (D), which is a non-invasive and effective treatment for BPPV. If the patient's symptoms persist or worsen, further evaluation and imaging studies, such as an MRI of the brain, may be necessary to rule out other potential causes of his symptoms.