What's in a Hiccup? Crack the Case

Andrew N. Wilner, MD


February 27, 2013

Clinical Presentation

A 78-year-old man complained of 1 week of dizziness and a tendency to fall to the right. He had headache with nausea and vomiting and developed hiccups. He denied dysarthria, dysphagia, sensory change, vertigo, and weakness. When the symptoms progressed so that he could no longer walk, he came to the hospital.

Medical history was notable for hypertension, chronic obstructive pulmonary disease, hyperlipidemia, migraine, and depression.

Medications on admission included aspirin 81 mg/day, atorvastatin 10 mg/day, lisinopril 30 mg/day, verapamil 240 mg/day, and escitalopram 20 mg/day.

He has no allergies, doesn't smoke, but drinks 4 highballs/day. He is retired and lives in a mobile home. Review of symptoms included chronic upper extremity tremor, left greater than right. He normally walks with a cane. Family history was noncontributory.

Physical exam revealed normal vital signs, a cardiac flow murmur, and no carotid bruits. Neurologic exam was remarkable for normal mental status, a small reactive right pupil, normal extraocular movements, a bilateral tremor with normal strength, symmetric reflexes and no Babinski sign, decreased pinprick in the left leg, past-pointing with finger to nose, worse on the right, and jerky heel-to-shin movements. He cannot walk without a walker and tends to fall to the right. He had trouble speaking because of intermittent hiccups.