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77 year old male presented to A and E .

His presenting complaint was dizziness with nausea and blurred vision. HOPC At 13.50 p.m the patient was making his bed and all of a sudden felt dizzy. When asked to explain what he meant by feeling dizzy he stated that the room was spinning. The Episode lasted a few seconds, and then he made his way to the stairs but used his buttocks to shuffle down the stairs. When he tried to get up, he felt off his leg. He also felt clammy and sweaty. The blurred vision had disappeared. There was no loc, parasthesia or history of trauma. It was at this point his wife called the ambulance. Since the incident the patient had had no recurrences. It was the first time the patient had this symptom and scared the life out of him. D/H Ibuprofen for Arthritis PMX Hernia operation in the groin 12 years ago F/H The patient stated all his brothers/sisters were well.

M/H Arthritis S/H Smoked 8 cigarettes a day for 50 years. Drank 3 pints of lager twice a week. History taking Learning points When I was taking history, I wanted to ascertain what the patient meant by feeling dizzy. This is when the patient stated that all the room was spinning. I also asked how long it lasted , in which he stated it was probably a few seconds. It was not improved by any position and patient couldn’t think of what exacerbated the problem. I asked what he had eaten in the morning. The Patient admitted he had a piece of toast. My reasoning of the questions I had asked were first to determine what he meant by feeling dizzy. According to page 302 of the Oxford handbook of Medicine Vertigo has been classed as Sensation of the world or patient moving, better when still, no loss of consciousness This could be caused by Labyrinth, Vestibular nerve, central connections of vestibular , e.g brainstem . There were no hearing changes like tinnitus.

I then approached my senior doctor. first the left one. and sensation in the upper and lower limbs. I checked his ears .After I had finished taking a history I decided to ask for blood pressure lying and standing to see if there was a deficit of 20mmhh. There was a postoral drop of more than 20mmgh. reflex. I ruled out Labyrinthis. As there was no hearing loss . The patient was well orientated. power. THE right ear had a build up of wax. The blood results came back and the CRP was high. E. The patient then admitted that his right ear had been aching for the last month. I asked the patient to walk to assess his gait. Before discharging the patient I asked if he had any chest pain and gave appropriate safety netting advice. the he could go home with a letter to the G. and then the right one. I then tried coordination which was finger to nose.P. a physical examination was needed. and bloods. Then I checked if Rombergs test. I needed to clarify if there were any cerebellar signs . At this point I was thinking of my differential diagnosis which were Vestibular neurontis which was difined as a viral infection of the vestibular nerve. FBC. but very alert. There was no signs of otitis media. U. In order to help with my diagnosis. and came on in the afternoon. I also checked for tone. I also wanted a urine sample. The doctor said if the patient was feeling fine. but my Senior decided that and the CRP was not something to be highly concerned about. I wanted to make sure that there were no problems in the patients ears. He was not clammy or pale. providing he didn’t have any chest pain. CRP and Amylase. I decided to assess eye movements and see if there was any nystagmus. . I would have thought that the postoral hypotension drop would be something to worry about.