Where you are:
You are an F2 in A&E.Who the patient is:
Harlow, aged 22, was out shopping in a supermarket, she turned her head and had a sudden episode of dizziness.What you must do:
Talk to the patient, assess her condition. Discuss the initial plan of management with the patient.
Don’t forget (viral infection few weeks before, lasts from hours to days, nausea, vomiting and hearing loss)
Doctor: What brought you to the hospital?
Patient: I was at the supermarket and when I turned my head I felt dizzy, I tripped and fell, someone helped me to get up and then she called the ambulance.
D: How are you feeling now?
P: I feel dizzy. (P1)
D: Are you comfortable speaking to me, would you prefer to lie down?
P: No, I am OK thank you.
D: So, what do you mean by dizziness exactly?
P: It feels like the room is spinning.
ODIPARA
D: When did this start?
P: 1-2 hours ago.
D: Is it continuous or does it come and go?
P: It is continuous.
D: Has it changed?
P: No.
D: Is anything making it better?
P: No.
D: Anything making it worse?
P: No.
D: Does it change when you move your head and neck?
P: No.
Explore the fall
Before
D: Any other symptom before having the fall?
P: No.
During
D: Did you make any jerky movements?
P: No.
After
D: Did you go unconscious after having the fall?
P: No.
D: Did you feel sleepy or confused?
P: No.
D: By any chance did you injure yourself?
P: No.
D: Did you bang your head on the floor?
P: No.
D: Anything else?
P: I am feeling sick. (P1, explore)
D: When did that start?
P: It started with the dizziness.
D: Did you vomit?
P: No.
D: Anything else?
P: No.
DDs
D: Any fever or flu-like symptoms? (Vestibular neuritis)
P: Doctor. 10 days ago, I had a sore throat and I took Paracetamol for it.
(+ve finding)
D: Any ear pain? (Labyrinthitis)
P: No.
D: Any feeling of stuffiness in the ear?
P: No.
D: Any ringing sounds in the ear? (Meniere’s Disease)
P: No.
D: Any problem with hearing?
P: No.
D: Do you have a headache? (Meningitis, Migraine)
P: No.
D: Any rash by any chance? (Meningitis)
P: No.
D: Any numbness, pain, or weakness on one side of the face? SOL (Acoustic
Neuroma)
P: No.
D: Any visual problem such as blurry vision or double vision? SOL (Acoustic Neuroma)
P: No.
D: Any weakness in your arm or speech problem? (TIA)
P: No.
(P2)
D: Has anything like this happened before?
P: No.
D: Have you been diagnosed with any medical condition in the past? DM, Heart diseases or ear problem?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any family history of a similar condition or chronic illness?
P: No.
DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Occasionally.
D: How is your diet?
P: It’s fine.
D: Are you physically active?
P: Not much.
D: What you do for a living?
P: I work as state agent.
D: With whom do you live?
P: I live with my family.
Examination
Is it OK with you if I check your vitals and examine your heart, ENT examination, hearing test and central nervous system examination?
I’d also like to send for some initial investigations including routine blood test and ECG.
Examiner says: ECG is normal and blood test results are awaited.
Provisional Diagnosis:
From our assessment, it seems like you have a condition called vestibular neuritis. In this condition one of the nerves in the brain, which sends signals from the inner ear to the brain, is inflamed. This nerve is responsible for maintaining our balance and our hearing.
You had the flu a few days ago. Sometimes the bug that causes the flu can affect this nerve and that’s why you may be experiencing these symptoms.
We did some examinations, and everything seems to be normal. We did an ECG and it was normal also.
Management
We will keep you in A&E for a while to take a closer look at you and reassess your symptoms.
Once your symptoms improve and you can tolerate fluids, we will be able to send you home with medication as this condition can be managed at home.
Investigations: We will do some blood tests to check anaemia or if there is any bug in your blood.
Senior
Symptomatic
The symptoms of vestibular neuritis usually settle over a few weeks, even without treatment. However, there are some self-help measures you can take to reduce the severity of your symptoms and help your recovery. Medication doesn’t speed up your recovery, but may be prescribed to help reduce the severity of your symptoms.
Self-help for vestibular neuritis:
- If you’re feeling nauseous, drink plenty of water to avoid becoming dehydrated. It’s best to drink little and often.
- If you have quite severe vertigo and dizziness, you should rest in bed to avoid falling and injuring yourself.
- After a few days, the worst of these symptoms should have passed and you should no longer feel dizzy all the time.
- You can do several things to minimise any remaining feelings of dizziness and vertigo. For example:
– Avoid alcohol, avoid bright lights and try to cut out noise and anything that causes stress from your surroundings.
– You should also avoid driving, using tools and machinery, or working at heights if you’re feeling dizzy and unbalanced.
Once the dizziness is starting to settle, you should gradually increase your activities
around your home. You should start to have walks outside as soon as possible. It may
help to be accompanied by someone, who may even hold your arm until you become
confident.
You won’t make your condition worse by trying to be active, although it may make you
feel dizzy.
While you’re recovering, it may help to avoid visually distracting environments such as:
supermarkets, shopping centres and busy roads etc. These can cause feelings of
dizziness, because you’re moving your eyes around a lot It can help to keep your eyes
fixed on objects, rather than looking around all the time.
Medication for vestibular neuritis:
Medications for severe symptoms, such as:
- Benzodiazepine - which reduces activity inside your central nervous system, making your brain less likely to be affected by the abnormal signals coming from your vestibular system.
- Antiemetic - which can help with symptoms of nausea and vomiting.
Specialist
If your symptoms persist or you develop any other symptom, your GP can refer you to the specialist and they may need to do some further investigations such as CT Scan or MRI, to exclude other causes.
Safety netting:
D: Is there anyone who can pick you from the hospital and get you home safely?
D: If you develop double vision, slurred speech. you start walking funny, weakness or numbness please come back to the hospital.