Case 27: Pamela Taylor

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history, examine this patient appropriately and tell the examiner your diagnosis and management plan.

INSTRUCTIONS FOR THE PATIENT, PAMELA TAYLOR

You are a 62-year-old woman who is normally well. You are caravanning around Australia with your husband, and yesterday you were relieved to reach a town where you could finally get to a hairdresser.

This morning you woke up as normal, but when you turned your head to check the view from the caravan window, you suddenly experienced an overwhelming spinning sensation in your head and marked nausea. If you stay still you feel OK, but whenever you turn your head the spinning and nausea return. The symptoms last less than a minute. You have not had anything like this before.

Your opening line is, ‘Doctor, I feel really dizzy’.

You have no tinnitus and your hearing is normal. You have no headache or any other neurological symptoms.

You regularly attend exercise classes in your home town, and your only medication is psyllium with ispaghula, one sachet once a day. In the past you have had surgery for a benign thyroid nodule.

You do not have any allergies, have never smoked and drink one to two standard alcoholic drinks at weekends.

Clinical examination findings

You will experience nausea when asked to move on and off the examination couch.

The candidate would observe nystagmus in your eyes during the Dix-Hallpike manoeuvre.

No other abnormalities are found on clinical examination.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open-ended questions to explore Pamela’s ideas, concerns and expectations.

Specific questions

Dizziness—spinning feeling or as if about to faint, episodic or continuous

Vertigo—relationship to position

Nausea and vomiting, diarrhoea—exclude gastroenteritis

Tinnitus

Change in hearing

Visual symptoms

Previous history of similar episode

Exclude

• — Fits

• — Cardiac cause

• — Head injury

Past medical history

• — Medication including OTC and complementary or alternative medicines

• — Allergies

Request permission to examine.

Examination

Cardiovascular system

• — Pulse

• — BP lying and standing

• — Heart sounds

Neurological examination

• — Cognitive function—no apparent problem

• — Cranial nerves

  III, IV, VI    eye movements, look for nystagmus

  VIII    otoscope examination, hearing

• — ...