Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in General Practice. Your next patient is 31-year-old Holly Morris complaining of dizziness. Please take a history and perform a relevant examination.
Patient History:
Holly Morris - 31 year old lady - works at a café.
You've been having spells of severe dizziness for about a week. When asked to clarify, you describe them as the room spinning around that usually lasts for half an hour. You get four or five episodes each day which are associated with nausea. You don't have palpitations.
Sometimes you feel like your hearing is reduced, but not always. You're not able to hear your friends' voices as clearly as you used to, and you must work hard to understand what they've said. You feel a sense of fullness in your ears.
Since last week, you've also had episodes of ringing in your ears and they've become much more frequent recently. It's a constant buzzing noise that has been irritating and stopping you from sleeping. The ringing is not pulsatile.
You have no facial weakness, fever or weight loss. You don’t recall ever developing arm weakness or difficulty speaking.
Ideas, Concerns, Expectations:
You initially thought this was just a lingering effect of the cold you recently had about one week ago, but the spells of dizziness are still persisting and awful. You really hope the doctor can tell you what's happening and prescribe medication to stop the dizziness.
Past Medical History:
Mild hay fever.
Migraines (usually classical headaches with zigzag vision beforehand)
Drug History:
Sumatriptan
NKDA
Family History:
Your father had a brain tumour which was removed. He is otherwise fit and well.
Social History:
You live at home with your husband and one 4-year-old boy. Things are going fine at home.
You work at the café you and your husband own.
You've never smoked and drink only on special occasions – your true passion is coffee.
Examination Findings:
Mild hearing loss – Rinne AC>BC in both ears, Weber lateralises to the left.
Negative Dix-Hallpike
HINTS exam = positive head impulse, no nystagmus, no skew.
Differentials:
Meniere's disease (vertigo, tinnitus, sensorineural hearing loss + aural fullness)
Viral labyrinthitis (vertigo usually prolonged episodes associated with hearing loss in the presence of recent infection)
Vestibular schwannoma (aka acoustic neuroma)
Central causes e.g. vestibular migraine, posterior stroke (less likely given HINTS exam findings)
Investigations:
Audiometry (will reveal low-frequency sensorineural hearing loss in Meniere's)
MRI (exclude vestibular schwannoma)
Management: