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 Junior Doctor working in General Practice. Your next patient is Katie Brown, a 55-year-old female presenting with a "funny turn". Please take a history and perform an appropriate examination.
Patient History:
Katie Brown, a 45-year-old female social worker.
Since a week ago, you have been getting these "funny turns". It comes on and off - occurring around 2 - 3 times a day. It can be triggered suddenly 5 seconds after turning over in bed, lying down, sitting up, leaning forward or turning your head. When this happens, it is often made worse by tilting the head to the right. You will begin to feel dizzy, like the room spinning around, which usually lasts for 30 seconds and then this completely resolves. Between these attacks, you feel completely normal and asymptomatic. Since a week ago, it has been more or less the same - not getting better or worse. You feel sick when you feel dizzy and can be unsteady. So far, thankfully, you haven't had a fall or vomited anything up!
No fever. No shivering or rigours. No hearing loss or tinnitus. No previous head injury. No ear pain or discharge. No photophobia. No stroke symptoms. No skin changes. No aura fullness. No neurological symptoms or signs.
Ideas, Concerns & Expectations:
You have no idea what is going on. It just feels really weird. You are not too concerned, to be honest, but you just want to find out what is going on.
Past Medical History:
Anxiety, migraine, hypertension
No previous relevant surgical history
Drug History:
Propanolol for anxiety.
Ramipril and amlodipine for blood pressure.
NKDA
Family History:
None
Social History:
Work as a Social Worker
Live with my husband in a flat
Do not smoke
Do not drink
Live independently without assistance
Examination Findings:
Dix-Hallpike Manoeuvre is positive indicating left-ear BPPV - symptoms of vertigo and rotational nystagmus (clockwise) when the head is tilted to the left and hung at the end of the bed. Care should be taken for patients with neck/back problems or cardiovascular problems e.g. carotid sinus syncope.
Ear Exam and otoscopy - normal
Cranial nerve / neurological examination - normal
Differentials:
Benign Paroxysmal Positional Vertigo (BPPV) - This is most likely as it's characterised by intermittent episodes of vertigo and nystagmus exacerbated by head movements in the plane of the semi-circular canal affected.
Acute vestibular labyrinthitis - Usually preceded by a viral infection but this is usually constant vertigo, even when the head is still (but exacerbated by movement in all planes) and is also associated with tinnitus & hearing loss which is not present here.
Vestibular neuritis - Also caused by viral infections, presents similarly to labyrinthitis; except that it does not present with tinnitus and hearing loss.
Acoustic neuroma - May present with vertigo, but usually also presents with hearing loss, facial numbness and tinnitus.
Meniere's disease - Does present with vertigo, but also hearing loss, tinnitus and a sensation of fullness within the ear.
Otosclerosis - Otosclerosis is unlikely to cause vertigo and would only occur more slowly and progressively and there is no history of hearing loss in our patient.
Multiple sclerosis - Often presents with signs of optic neuritis, and may have cerebellar, motor and sensory issues.
TIA/stroke - Vertigo is present in posterior circulation and cerebellar stroke, but often also presents with other neurological signs such as ataxia, dysdiadochokinesia, intention tremor, slurred speech...etc.
Investigations:
Bedside:
Clinical diagnosis - based on history and examination findings
Lying and standing BP - rule out postural hypotension as a cause of dizziness
ECG - Consider if cardiac history or concerns of a cardiac cause of dizziness
Dix-Hallpike Manoeuvre (posterior/anterior canal BPPV)
Supine Lateral Head Turns Manoeuvre (lateral canal BPPV)
Imaging:
Consider CT / MRI - if concerned about haemorrhage, stroke, tumour or if the diagnosis is uncertain (MRI with contrast if concerned about acoustic neuroma)
Data Interpretation: