Embedded Files
· FM&PH – Dizziness
· FM&PH – Dizziness
· In module Family Medicine and Public Health
· Four patients present to Dr Demetriou with dizziness one afternoon at the GP surgery.
·Guidance and Resources – Dizziness
Further Case Information – Dizziness
Background Science – Dizziness
Case Conclusion – Dizziness MED 35
Formative Assessment – Dizzines
Guidance and Resources – Dizziness
Guidance and Resources – Dizziness
In case FM&PH – Dizziness
Learning Resources
Learning Resources
Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.
You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.
Recommended Reading
Recommended Reading
For short summaries of approaching undifferentiated presentations of dizziness:
· Overview of dizziness: Dr Sarah Jarvis explains Dizziness
· Overview of dizziness: Dizziness, Giddiness and Feeling Faint
For a brief practical written summary of BPPV
Watch a short video on how to do the Dix-Hallpike Manoeuvre from BMJ Learning:
Additional Resources
Additional Resources
Prescribing Skills Handbook 1 and Prescribing Skills Handbook 2 (iBook link)
BNF (Must be viewed using university wifi or with the VPN)
If you would like to know more about advising patients about noise protection read the Health and Safety information by the Health and Safety Executive
The vestibular system can be revised at the following:
BMJ: Vertigo and Imbalance (you will need a login for this off campus)
If you would like to go over basic interpretation of ECGs these short videos are useful: https://youtu.be/tnJsol9sWfA
NICE guidance on Atrial Fibrillation
Check out an example of good patient Information about AF
For advice on tackling difficult consultations with Adolescents and Young Adults
NICE guidance on diagnosing Eating Disorders
CASE COMPONENT
Case Introduction – Dizziness MED 35
In case FM&PH – Dizziness
Case 1: Tami
You are a 4th year student and Dr Dimetriou is your GP Tutor who you are sitting in with today. The afternoon surgery is just about to start when the receptionist phones through to ask if Dr Dimetriou can take an urgent call from a patient before her afternoon list starts. Dr Dimetriou asks if you would like to conduct the phone consultation, which you are pleased to do. Dr Dimetriou gains consent of the patient for you to take the lead on the questions, with the GP tutor listening and contributing via speaker phone. You know that the patient is a 42 year old woman called Tami, who has requested an urgent telephone consultation for dizziness.
Take a moment to think about what would be your initial questions? Why are you asking them? How will they help you form any potential differential diagnoses?
Match these possible questions with the information it gives you
Answers
You are trying to narrow it down in order to apply medical semantic qualifiers. This is a process of translating what she says into medical descriptions of lay terms. Doing this helps you to activate recall of your prior medical knowledge.
Tami has been light-headed since getting up out of bed this morning. There has been no fever, no palpitations or chest symptoms. She has felt nauseous for the past few weeks, and vomited twice this morning but then felt better and went to work. She had to come home at lunchtime however as she felt dizzy. She is normally well but has felt tired all the time for 2 weeks and is now passing urine more frequently.
Her main concern is making it to her sister’s wedding tomorrow. She asks, ‘Could you just send a prescription over to the pharmacy for something to stop the dizziness?’
This a reasonable course of action
True
False
False
You have not identified any likely causes for her problem or ruled out serious differential diagnoses yet, so it would be premature to prescribe at this point in the consultation.
You explain you’d like to ask some more questions before you know if prescribing something is the right thing. When you ask about medication, Tami mentions she took some Tramadol (that her husband had in the cupboard) when she came home from work at lunchtime for some left sided abdominal pain. It helped quite a lot. She thinks the pain is caused by constipation, although admits that it is unusual for her not to open her bowels normally. She has last opened her bowels 2 days ago, but on further questioning the motions were normal in colour and form. She has not had any change in her dizziness since taking this medication.
What are the common side effects of Opioids? (Select THREE)
· Nausea and vomiting
.
Correct answer.
· Itch
.
Correct answer.
· Jaw pain
.
· Drooling
.
· Constipation
.
Correct answer.
· Aching legs
This is an example of a patient using ‘self-care’; Tami has tried something herself before seeking professional advice.
What sort of things could people try to help constipation?
Increasing physical activity, fruit, fibre and fluids. There are also several over the counter (OTC) medications available for constipation.
IN PRACTICE:
Go to a local pharmacy and have a look at the various treatments for constipation available over-the-counter. Compare what is available to the BNF.
You end this consultation and await Tami to arrive at the surgery. Dr Dimetriou informs the receptionists to let you know when she arrives so that she can be seen immediately.
Dr Dimetriou calls in the first patient on the afternoon list.
Case 2 – Peter
A 62-year-old man called Peter comes for his annual medication review.
It might be useful at this point to remind yourself of the chapter about Prescription review, in Prescribing skills handbook 1.
Peter is happy that his Proton Pump Inhibitor (PPI), Omeprazole 20mg once per day, controls his heartburn secondary to a hiatus hernia diagnosed by the specialists with upper GI endoscopy 12 months ago. His blood pressure has been controlled on ramipril 2.5mg for the past 10 years, and Amlodipine 5mg for the past 5 years, and he is having no unwanted side effects.
Peter mentions that there is something he wanted to ask about. He is embarrassed about a rash. It’s in his groin and started with some chafe on holiday. Dr Dimetriou examines him with his consent and his consent for you to be present, and a chaperone, and sees the following:
If you had to describe this rash over the phone to a colleague what would you say?
One suggestion is a ‘well-demarcated flexural pink rash in a hair bearing area with a slightly raised edge, typical of fungal infection’.
One suggestion is a ‘well-demarcated flexural pink rash in a hair bearing area with a slightly raised edge, typical of fungal infection’.
What do you think the GP should do to help Peter with his rash?
· Refer Peter to a Dermatologist
.
Fungal skin infections can be successfully treated in primary care. If recurrent, you might consider testing for immunocompromise, including HIV and diabetes. You then might seek the help of a Dermatologist or Infectious Disease specialist.
· Tell him not to use the communal showers at the gym
.
You don’t catch fungal infections in the shower from other people. In fact delaying showering after exercise might allow the fungus to thrive in a sweaty, warm, moist, dark environment for longer.
· Prescribe a topical antifungal medication
.
Correct answer.
This would be the first line for a fungal infection at first presentation. Some of these preparations are available over the counter.
· Advise him politely to wash more often.
.
Over-washing removes protective flora from the skin and makes space for fungal infections to proliferate. Once a day with a mild soap-free unscented cleanser and lots of water is enough.
· Advise him to use some antiseptic cream from the supermarket
.
Antiseptics will destroy his protective skin flora and could make it worse.
What the GP decides to do
The GP gives a prescription for clotrimazole cream.
As he is leaving after 10 minutes, Peter asks about whether he should continue exercising as he has been a bit dizzy on a couple of occasions on the treadmill at the gym.
You should ask him to rebook to discuss
True
False
False
At the very least this needs assessment for severity of the problem. Hand-on-the-doorknob consultations are often reflective of the patients’ real concerns.
What the GP decides to do
The GP asks Peter to come back and take a seat. Dr Dimetriou asks him to tell him more about it.
Take a moment to think about what would be your initial thoughts? What specific things would you want to know about? How do they help you form any potential differential diagnoses?
Remember the questions to ask from earlier.
You are then trying to narrow it down in order to apply medical semantic qualifiers. This is a process of translating what he says into medical descriptions of lay terms. Doing this helps you to activate recall of your prior medical knowledge.
Peter is happy for you to ‘hot seat’ the consultation. You find out that the dizziness comes on with exercise and is relieved by rest after a few minutes. He feels light headed and a little short of breath, but there is no chest pain. He has no cough or wheeze. The occasional palpitation has accompanied it, but he shrugs it off and seems keen to get back to training. He is unsure if this is regular or irregular. He has had no ear pain or hearing loss. He has had no head trauma, and no headaches, visual problems or weakness of his arms or legs.
Does this information change your thinking about asking him to rebook? Are there any other factors which could influence the decision?
It is still difficult to know if this symptom represents something serious or not. However, it is important to recognise that your decision could also be influenced by many factors such as how you are feeling (HALT*), whether there are other more urgent patients to see, and the non-verbal cues you have about the severity of his symptoms or the patient’s perspective.
*HALT = Hungry, Angry, Late, Tired.
Reflect on how these affect your decision-making.
Having a full bladder affects your cognition to a degree similar to being at the legal drink driving limit.
Select the appropriate examinations you would perform based on the information obtained so far:
His cardiovascular examination showed:
· Pulse 56/min, regular rhythm.
· BP 132/78.
· Heart sounds normal.
· BMI 22.
· He has a clear chest.
· A neurological examination did not show gait ataxia or impairment of finger-nose coordination.
· His abdomen is soft, non-tender and he has normal ear canals and drums.
You check out Peter’s medical record during the consultation:
· 12 months ago: Hiatus hernia. Bloods at the time were all normal including his FBC, U+E, LFTs, HbA1c and fasting lipids, with a Qrisk of <10%. He is due repeat blood tests and his medication review.
· Never smoked cigarettes
· Teetotaller: He stopped drinking alcohol completely a year ago because it aggravated his dyspepsia. He has a very healthy diet and drinks Kale smoothies for breakfast every day.
· No family history of heart disease.
What do you want to do now? (Select best TWO)
· Reassure him that the examination is normal and he will be fine
.
There are some tests you need to investigate before you can reliably reassure him
· Book an appointment for a 12 lead ECG with the nurse or via local referral pathways at the hospital
.
Correct answer.
His history of palpitations and breathlessness with dizziness is suggestive of a cardiovascular cause and this would be a good baseline test.
· Advise him to stop all exercise until he is seen by a cardiologist
.
Exercising is not going to be harmful, but he should recognise his limits and stop when he becomes symptomatic.
· Arrange some blood tests
.
Correct answer.
This patient is due his blood tests and important differentials can be excluded at this stage such as anaemia, electrolyte disturbance and thyroid disorders.
· Stop the PPI
.
Dizziness is a ‘less frequent’ side effect of PPIs. You might consider this at a later stage if once some more investigations have been performed.
What the GP decides to do
Dr Dimetriou arranges some blood tests to monitor his medications, puts a request through for a 24 hour ECG and arranges to see Peter within the next 2 weeks. She advises him that if he gets any prolonged symptoms, or any new symptoms in the meantime, to seek urgent medical attention. Peter leaves happy that things are being investigated.
Dr Dimetriou calls in the next patient.
Case 3 – Lloyd
Lloyd is a 28-year-old music student at the Royal Northern College of Music. He is specialising in percussion. He has missed his exam this week because of dizziness and has come in to the surgery to request a letter from the GP for mitigation. He is usually well. Dr Dimetriou asks if you would like to lead this consultation, and gains consent from Lloyd.
Take a moment to think about what you would want to know. What questions would you ask? What information does this give you to help with the differential diagnosis?
Remember the questions to ask from earlier.
You are then trying to narrow it down in order to apply medical semantic qualifiers. This is a process of translating what he says into medical descriptions of lay terms. Doing this helps you to activate recall of your prior medical knowledge.
You discover that Lloyd has dizziness which he describes as the room spinning, which is worse on moving his head. He is really worried because he has also been experiencing a sense of fullness in his ears, when he thinks his hearing isn’t as good as it should be, and intermittent tinnitus. He has no ear pain or discharge. He has no dental problems. He has had no fevers and is systemically well. He says he has not tried anything over the counter, but reluctantly admits that he has been smoking cannabis.
The vestibular system can be revised looking at:
· Meducation: Balance and dizziness
Dr Dimetriou outlines to you that this combination of symptoms is suggestive of Meniere’s Disease or Benign Paroxysmal Positional Vertigo (BPPV).
You will also be familiar with the concept of asking about ‘red flags’ to ensure that a serious diagnosis is not missed.
Are there any other specific red flag questions you need to ask in this case, which has not already been covered?
Unilateral tinnitus – in people with this it is important to exclude a vestibular schwannoma by referring to ENT for consideration of an MRI scan.
Dr Dimetriou checks and Lloyd describes tinnitus intermittently in both ears. His band is called ‘Rule of Rock’ and they are hoping to play at a festival in the summer and thinks his symptom are worse after playing with the band.
You examine Lloyd using the Dix-Hallpike manoeuvre.
ACTIVITY
Watch a video on how to do this test:
The Dix-Hallpike manoeuvre is positive, what does that mean?
The positive predictive value of a positive Hallpike test result for a diagnosis of benign paroxysmal positional vertigo (BPPV) is 83%, with a negative predictive value of 52%. This increases the chance of this being BPPV but is not definite.
What other investigation would be useful?
An audiogram. This is important to test his hearing, and define the nature of the hearing loss. If any unilateral hearing loss were detected, this may warrant urgent referral to ENT. If any hearing loss detected, Lloyd should be referred given his occupation, and in any case, he should be advised to seek advice from his college regarding ear protection.
Make a problems list for Lloyd
Positional Vertigo
Hearing loss and Tinnitus – may be related to his history of noise exposure. This is high stakes for professional musician. He needs professional advice on noise protection. The positive Dix-Hallpike increases the likelihood of this being BPPV but does not definitely diagnose it.
Recreational drug use – jeopardises his health and his engagement with his studies and may be contributing to his current symptoms.
Is there anything you can do practically to help Lloyd at this point, given a working diagnosis of BPPV?
1. Try the Epley Manoeuvre. Watch the video below.
Advise about noise protection and against recreational drug use, pus salt, caffeine and alcohol restriction
Advise about noise protection and against recreational drug use, pus salt, caffeine and alcohol restriction
Dr Dimetriou describes the Epley Manoeuvre and advises Lloyd to be careful with bending and moving head up and down, and advises he try to sleep at a 45% angle for the next couple of nights, and try to maintain horizontal movement of the head to prevent neck stiffness.
She arranges a review of Lloyd in a couple of weeks, by which stage they should also have the results of the audiogram.
Lloyd is happy with this plan, but asks if Dr Dimetriou can do anything about his missed exam.
Which option is best? There is one best answer
· He didn’t consult before or on the day of the assessment so you can’t give him a letter for mitigation
.Correct answer.
You can explain sympathetically that you understand his situation but unfortunately you cannot issue a letter for mitigation.
· He can fill in a self-certificate for absence from his course.
.Self-certification is used for work, not study.
· He can collect a letter from reception in 5 days’ time. There will be an admin fee payable because this is not core NHS work.
.You have no evidence he was ill on the day of his exam and therefore it would be a probity issue if you issued a letter for mitigation.
· He didn’t consult before or on the day of the assessment so you can’t give him a letter for mitigation
.
Correct answer.
You can explain sympathetically that you understand his situation but unfortunately you cannot issue a letter for mitigation.
· He can fill in a self-certificate for absence from his course.
.
Self-certification is used for work, not study.
· He can collect a letter from reception in 5 days’ time. There will be an admin fee payable because this is not core NHS work.
.
You have no evidence he was ill on the day of his exam and therefore it would be a probity issue if you issued a letter for mitigation.
Lloyd understands and leaves happy with what has been done to try to address his dizziness.
Dr Dimetriou calls in her next patient:
Case 4 – Kelly
Kelly is 16-years-old and comes with her Mum. Both are happy for you to lead the consultation, under supervision of Dr Dimetriou, and Kelly is happy for her mum to be present for the consultation.
She has been sent home from school feeling dizzy, twice this week and then again today when she ‘fainted’. Mum says she has been well at home. Kelly doesn’t seem to be engaged with the consultation. You note that Kelly has ‘anxiety’ on her medical record, and has been seen by the Child and Adolescent Mental Health Service (CAMHS).
How might you proceed with this consultation in order to develop some rapport? Remember your Calgary Cambridge framework which you have worked on during PCC in Year 3, and what might be needed to consider when consulting with young people.
Consider the impact difficult experiences may have had her development. Teenagers may be emotionally less mature than their age and experience might suggest. Be authentic in your interest and try to offer genuine warmth in the encounter. They may be afraid of what might happen but can display this as indifference.
You decide to start by having a chat with her about school. What she likes and what she doesn’t.
Kelly starts by saying about her exams this year, which are important as she needs good grades to get her university place. She says that she likes PE, but she was ‘dizzy’ at assembly because it was ‘boring’ and then she fainted. She feels fine now and just wants to go home.
Would you be happy to let Kelly leave at this point?
· Yes, absolutely
· No, probably not
· No, probably not
.Correct answer.
You need some more information. It may help to acknowledge her point of view but ask if it’s ok just to ask a few more questions before she goes.
Take a moment to think about what you want to know. What would be your next questions? Why are you asking them? How do they help you form any potential differential diagnoses?
Remember the questions to ask from earlier.
You are then trying to narrow it down in order to apply medical semantic qualifiers. This is a process of translating what she says into medical descriptions of lay terms. Doing this helps you to activate recall of your prior medical knowledge.
You carry on with the consultation and Kelly seems to be opening up as you are using your communication skills to build rapport, including appropriate eye contact and using language which Kelly can understand, avoiding jargon.
The dizziness is worse on standing up quickly or waiting around for a long time. It is a lightheaded feeling and sometimes she can ‘see stars’ before she falls to the ground. Kelly’s friend told her that her eyes rolled back and she was jerking for a second this morning in assembly. Kelly herself says that she has felt ‘fine’.
What are you thinking now? Why? What other questions might you ask?
It is important to work out what the friend meant and gain more detail about this. It is important to think about seizure activity. You will need to find out more detail about this, ideally from the witness directly but if not possible, from Kelly, if she knows any more detail or her mum. Questions will be those to suggest seizure activity such as a consistent history of jerking, tongue biting, incontinence and anything which might suggest a post-ictal phase.
There may also be a history of staring into space with absence seizures. See the video below from your Year 3 TLOC case.
Dr Dimetriou discovers that Kelly was not incontinent, did not bite her tongue and was completely better within a few seconds of the episode. The friend who saw it has a brother with epilepsy and she said it didn’t look like a fit. Kelly’s mum said that a teacher also witnessed the episode and said that there were no features of a seizure.
Dr Dimetriou says that it sounds as though there is less supporting evidence now for this being a fit. She asks if she has had any other symptoms, including any shortness of breath, chest pain or palpitations. Kelly denies any particular symptoms but admits that she does feel anxious at times, particularly about social events. She admits to drinking alcohol sometimes as it ‘calms her nerves’ and this week she has felt tremulous so had more than usual, but doesn’t usually like to drink ‘too much as it is full of calories’ .
Dr Dimetriou suggests at this point it would be a good idea to check Kelly’s blood pressure and pulse. You do this and both are normal. You also ask Kelly if you can auscultate her heart and lungs, both of which are normal, as is her oxygen saturation.
Is there any other measurement which can be done now which might help make a diagnosis?
· 24 hour ECG
· Lying and standing BP
· Chest xray
· ECG
· 24 hour ECG
· Lying and standing BP
.Correct answer.
This history could be suggestive of postural hypotension as a cause of the dizziness. Lying and standing blood pressures are a test which can be done immediately within this consultation. An ECG and 24 hour ECG may well be useful investigations if the lying and standing BPs are normal, but are not necessarily possible to do immediately in the GP consultation. Given the lack of respiratory symptoms and a clear chest and normal saturations, coupled with the radiation risk of an xray, a chest xray is probably not going to be the best first investigation.
· Chest xray
· ECG
How do you check for postural hypotension? Pick 1 correct answer
· Check the BP lying down then again as soon as she sits up. Ask about symptoms.
· Check the BP sitting then again at 1 minute after standing
· Check BP lying then after standing at intervals of 1, 3 and 5 minutes.
· Check BP lying then after standing at intervals of 1, 3 and 5 minutes. Ask about symptoms
.Correct answer.
Remember asking about symptoms is key to the diagnosis
Check the BP sitting then after standing for 2 minutes. Ask about symptoms
You check Kelly’s lying and standing blood pressure and find that there is no postural hypotension just now. As Kelly has taken off her jumper to be examined, you notice that she looks quite thin. You suggest a height and weight to calculate her BMI. You can revise how to work out a BMI from the primary prevention case in GP week 2.
Kelly has a BMI of 18.1 (underweight)
Does this information change your thinking? What are your differential diagnoses and why?
1. Anxiety – already on the records and receiving treatment through CAMHS. You will cover/have covered about anxiety in your Mental Health block and would be an area which the GP would explore further.
2. Eating Disorder – supported by low BMI, concern about calories. For a diagnosis of anorexia nervosa, the BMI would need to be below 17.5kg/m2 but there are other eating disorders which the BMI may not be low.
3. Alcohol dependence – using it to calm symptoms of anxiety may indicate withdrawal
4. Hyperthyroidism – low weight, anxiety.
5. Safeguarding concern – can be associated with anxiety or mental health disorders, low weight due to neglect?
Think about a question for Kelly around each differential diagnosis, and say it out loud to practice!
Think about a question for Kelly around each differential diagnosis, and say it out loud to practice!
Kelly denies any other symptoms to support hyperthyroidism. You ask about the drinking and discover that there is no evidence to support dependence. Kelly says that her mum cooks her meals at home, and that no-one is mis-treating her, and that she has a good relationship with her mum who she would talk to if she had any problems. She also has a good relationship with the school nurse who has been recently helping her, alongside a counsellor from CAMHS, to help with her anxiety, which Kelly and her mum say is currently not too troublesome. Her mum says that Kelly had always been ‘skinny’.
What is the role of a school nurse?
The National Association of School Nurses (NASN) defines school nursing as a specialised nursing practice that advances the wellbeing, academic success, lifelong achievement, and overall health of students.
Day-to-day duties may include:
· raising awareness of health issues like smoking and drug abuse
· promoting healthy living, including safe-sex education
· giving immunisations and vaccinations
· carrying out developmental screening
· training teachers on healthcare issues
· advising on school health policy
· supporting children with medical needs like asthma, diabetes, epilepsy or mental health issues
· work closely with others, including GPs and social services, in child protection cases where required
(Reference: https://nationalcareersservice.direct.gov.uk/job-profiles/school-nurse)
You ask her how she feels about her weight; Kelly admits reluctantly that she has been ‘on a diet’ for the past couple of weeks, and had decided not to eat anything except apples in an attempt to ‘look thinner’ for the end of term Prom. She denies any binging, vomiting or associated drug abuse.
Her mum is shocked and hugs Kelly telling her that she is beautiful as she is. Kelly is upset and feels that she should’ve known better and says that ‘I know I’m not even fat’.
Dr Dimetriou suggests that this could have been the cause of Kelly’s dizziness for the past week, as apples will not contain the nutrients the body needs over a period of a few weeks. In the absence of any other symptoms or findings on examination, she asks if Kelly feels able to come off this diet to ensure that her symptoms resolve. Kelly says she will as she has felt terrible at school for the past week, and was coming to realise that the diet was not good for her as she has been frightened by her dizziness this week. Dr Dimetriou suggests that they book another appointment in a couple of weeks, to ensure that the symptoms have resolved with a normal diet. She also outlines that if she eats normally and still gets symptoms, or any new symptoms, Kelly should seek medical advice sooner.
How would the GP ensure continuity of care for Kelly at the practice?
A GP can ask a patient to book follow up appointments specifically with them. In this case, the GP would make sure they are not timed for when Kelly should be at school. If the GP is part-time, or going on leave, they might want offer to introduce her to one of the other doctors or a nurse who is in on the days they are not at the practice.
Why might Dr Dimetriou ensure another appointment with Kelly?
1. There may be concerns that Kelly may be vulnerable due to alcohol use and anxiety symptoms. Further evaluation and support may be required. Dr Dimetriou might try to speak to the School Nurse prior to the follow-up appointment do discuss these concerns. It is good practice to inform the patient and her parents about this beforehand. Remember however that if there were a safeguarding concern requiring referral or immediate action, it is good practice to inform the person and/or parent where appropriate, but you do not require their permission to do so.
2. One 10 minute appointment may not be enough to develop full trust and rapport for Kelly to feel comfortable should she need to disclose any other issues
3. It would be a good idea to monitor Kelly’s BMI. There may be an underlying eating disorder or physical disorder, which would need further evaluation.
Kelly leaves with her mum and books an appointment for review in 2 weeks.
Tami returns
At the moment that Kelly leaves, Tami arrives in her tax and is seen when she arrives by yourself and Dr Dimetriou. She says she feels very lightheaded. You gain her consent to examine her.
· Her BP is 96/50 and her pulse is 108/min.
· Her abdominal examination is normal.
· She is afebrile.
· The urine dipstick is negative for blood, protein, leucocytes and nitrites.
What would you ask next? Consider the reasons why each question is important.
You want to find out why she is hypotensive and tachycardic. One line of questioning you might have considered is about any further specific symptoms or signs to suggest sepsis or acute blood loss.
You might also consider asking about her last menstrual period (LMP). A differential in this case, in the context of Tami’s tiredness and nausea in a woman of childbearing age, is ectopic pregnancy.
Appendicitis/ruptured appendix and pelvic inflammatory disease are other differentials, although this might be associated with fever.
The GP must always make sure that potentially life-threatening and/or urgent diagnoses are not missed. Remember the Tramadol may be masking her pain severity when you examined her.
Tami tells you that she has not seen any other blood loss or discharge, nor any other pain other than in her lower abdomen this morning, and has had no fevers. Her periods have been sparse and irregular for 6 month, and her sister said it could be due to her contraceptive pill, so she stopped using her usual progesterone-only contraceptive pill 3 months ago. She has not had any post-coital bleeding and is up-to-date with her smears. Since stopping her pill, she has had 2 episodes of unprotected sexual intercourse (UPSI).
What tests are you going to do and what do you need to explain for consent to this?
You explain that there is a risk of pregnancy due to her not using her contraceptive pill, and it is very important that you test her urine for this. You may also want to take a sexual history to assess her risk of Sexually Transmitted Infection (STI) as she is complaining of urinary frequency. The pregnancy test is weakly positive.
How reliable is a urine pregnancy test?
· 75%
· 97%
· 100%
· 50%
· 97%
.Correct answer.
Home pregnancy tests are around 97% accurate when done on the day of the first missed period. GP Surgeries use similar tests.
What do you want to do next?
· Prescribe some HRT patches
· Ask her to repeat the pregnancy test again tomorrow with the first urine sample in the morning?
· Let her go home as long as she books an appointment with the midwife next week
· Prescribe a laxative and a stronger painkiller (checking in the BNF that they are suitable in pregnancy) so she can go to her sister’s wedding
· Admit urgently to hospital by emergency ambulance
· Prescribe some HRT patches
.She is not complaining of menopausal symptoms. Her irregular periods could have been due to her contraception (remember your learning from week 2 of the GP block link) but this will need following-up at a future appointment as there are other causes. HRT is not to be used for contraception.
· Ask her to repeat the pregnancy test again tomorrow with the first urine sample in the morning?
.There is no need to repeat the test with an Early Morning Urine (EMU). This would cause unnecessary delay.
· Let her go home as long as she books an appointment with the midwife next week
.Booking with the midwife for routine antenatal care may be important at a later date, but Tami should not be allowed to go home at this point and would not be your priority in this scenario when the patient is hypotensive and we are concerned about ectopic pregnancy. You might let Tami know to rebook for a further appointment when more is known about this acute presentation today, either with yourself and/or the midwife.
· Prescribe a laxative and a stronger painkiller (checking in the BNF that they are suitable in pregnancy) so she can go to her sister’s wedding
.Despite the patient’s concerns and expectations you have identified a potential emergency and must act on it.
· Admit urgently to hospital by emergency ambulance
.Correct answer.
This is the safest course of action. You are unable to rule out a serious cause for your examination findings. She is at risk of collapse and must not drive herself.
Dr Dimetriou arranges the ambulance and admission to hospital, and sites and flushes a large bore cannula in her antecubital fossa whilst waiting for the ambulance.
CASE COMPONENT
Further Case Information – Dizziness MED 35
In case FM&PH – Dizziness
2 weeks later. You are back in surgery with Dr Dimetriou.
Case 2 – Peter
Peter is back to see Dr Dimetriou for the results of his investigations. His blood tests were all normal.
The 12 lead ECG was normal.
Take a moment to reflect on what you were thinking and what you are now thinking about Peter’s case. Have your differentials changed now you are seeing him with the ECG? What do you want to do now?
The history His symptoms are intermittent and may not have been captured by the 12 lead, which is a just a snapshot. You need to capture an event. The result has already been seen by one of the GPs in the practice, who reviewed the notes and arranged a 24 hour ECG recording, which has also been done.
What the GP decides to do
The 24hr ECG shows 2 episodes of Paroxysmal Atrial Fibrillation (PAF).
IN PRACTICE:
Observe how your GP Tutor approaches a patient with an abnormal result. You have come across techniques for sharing information during Year 3 PCC, and will do/have done more about breaking bad news in Year 4. See other techniques which your GP Tutor utilises. See what information the GP provides for patients to help explain results. Could you try explaining a result to a patient?
Dr Dimetriou uses ‘SPIKES’ model to share the news about this diagnosis. You have come across this during your PCC sessions, in the context of sharing information with patients and you will do more about this specifically relating to ‘Breaking Bad News’ during Year 4. There is more information about this in week 2 of the GP block, when the GP outlines to Mrs Gerald about her referral for suspected cancer. In addition, you have learnt about Atrial Fibrillation in Year 3.
Dr Dimetriou explores Peter’s perspective and prior knowledge, and explains AF to him.
IN PRACTICE:
Ask your GP if you can explain ‘AF’ to them, or practice with a friend. It is helpful to always consider how you would communicate diagnoses to patients in language they would understand, avoiding jargon.
The GP gave Peter a Patient Information Leaflet (PIL) printed from the computer system. Dr Dimetriou also directed Peter to a website that the GP was sure contained reliable information.
IN PRACTICE:
See which ‘decision aid tools’ are used within your GP practice to work out risk of stroke with atrial fibrillation, and risk of bleeding. It is important that you are familiar with the information the tool provides, so that you can discuss the outcome with the patient in language they understand. You might also want to revise the information in case relating to ‘absolute’ and ‘relative risk’.
You might also want to review the NICE Guidelines.
In this case, the GP finds that anticoagulation is indicated, and discusses this and the pros and cons of treatment (and ‘no treatment’) options. Peter decides to read the information provided and asks to rebook to discuss with Dr Dimetriou again when he has thought about all that has been said so far. He is competent to make this decision and Dr Dimetriou is happy to see him again at a time of his choosing.
She calls in the next patient.
Case 3: Lloyd returns
Dr Dimetriou starts the consultation by outlining that his audiogram is normal – much to Lloyd’s relief, but she outlines that ear protection really is vital given his career aspirations.
You ‘hot seat’ again and discover the vertigo is improved, but still troublesome and Lloyd wants to try some medication. He has had no further tinnitus, fullness of the ears and no hearing loss.
Which of these medications might help? (Select ALL that apply)
· Vestibular rehabilitation exercises
· A vestibular sedative such as cyclizine, cinnarazine, or prochlorperazine.
· A benzodiazepine such as Diazepam to calm him down
· A diuretic such as Furosemide to reduce fluid in the inner ear
· A vasodilator in the inner ear called Betahistine
· Vestibular rehabilitation exercises
.Correct answer.
These are indicated and would avoid possible side effects and delayed recovery of the vestibular sedatives.
· A vestibular sedative such as cyclizine, cinnarazine, or prochlorperazine.
.Correct answer.
These medications could be offered to patients, but may slow recovery and patients need to bebeware of side-effects.
· A benzodiazepine such as Diazepam to calm him down
.Benzodiazepines are not recommended as first line treatment for anxiety and will not help his vertigo.
· A diuretic such as Furosemide to reduce fluid in the inner ear
.Diuretics do not reduce fluid in the inner ear and can in fact cause tinnitus
· A vasodilator in the inner ear called Betahistine
.Correct answer.
This may help in some cases. Be sure to review the response and stop it if it isn’t helping
Dr Dimetriou also outlines again that he needs to protect his ears from excessive noise, and advises against his recreational drug use. Lloyd this time seems much more receptive to this advice, as he says that he doesn’t want to be taking medications in the long term. He thanks you both and says he will return in a couple of weeks if things haven’t improved.
CASE COMPONENT
Background Science – Dizziness MED 35
In case FM&PH – Dizziness
In any history of dizziness you need to establish whether the patient experiences vertigo, disequilibrium or pre-syncope. Drugs, both prescribed and recreational, are a common cause of dizziness.
Generating a problems list can be a good start. You can then use a systems approach to generate your hypotheses about possible differential diagnoses.
One way of thinking about this is using a mind map
CASE COMPONENT
Case Conclusion – Dizziness MED 35
In case FM&PH – Dizziness
One of the most satisfying things about being a GP is undertaking longitudinal care of your patients: Find out here what happened….
Case 1 – Tami
Tami was seen immediately at hospital and diagnosed with ectopic pregnancy. She went to theatre for a salpingectomy for a ruptured left fallopian tube the same afternoon and needed a blood transfusion post-operatively. She recovered well and now has a Mirena coil for contraception which is suiting her.
Case 2 – Peter
After several discussions with the GP over a couple of appointments regarding the relative benefits and risks of anticoagulation, and then the choice of anticoagulation, Peter decides on warfarin. You done some work on atrial fibrillation, scoring systems and anticoagulation during Year 3 which you should be familiar with, and will cover more about this topic during Year 5.
Case 3 – Lloyd
Lloyd was better in time for his summer re-sit exams . His lifestyle modifications really helped. He had some specialist earplugs made. The next time he saw the GP was several years later when he brought his first child for her baby check.
Case 4 – Kelly
Kelly came back to see Dr Dimetriou and built a good relationship with her. She had further appointments for the next 6 months with the Child and Adolescent Mental health Service (CAMHS) and they helped her with her anxiety. Her BMI has been stable at 19 for the past few years, and taking up exercise has really helped. She became a sprinter for the school athletics team, and then continued this at University, seeing Dr Dimetriou occasionally with a recurrent ankle sprain.
Formative Assessment – Dizziness
Indicate which of the following statements are TRUE in relation to Atrial fibrillation (Select TWO)
· Transoesophageal echocardiography (TOE) should be done to exclude a structural cardiac abnormality
· Most people with AF have an identifiable cause
· AF is more common in females
· The distinguishing feature of AF is variability in the R-R intervals
· Paroxysmal AF is defined as spontaneous termination within two days and most often within 4hours
· The biggest risk for patients with AF is haemorrhagic stroke
· Most people with AF have an identifiable cause
.Correct answer.
· The distinguishing feature of AF is variability in the R-R intervals
.Correct answer.
Indicate which of the following statements are TRUE in relation to Syncope. (Select THREE)
· Orthostatic hypotension is defined as a drop of BP >20/10mmHg within three minutes of standing
.The definition also includes the presence of symptoms of syncope or presyncope.
· Midodrine is a useful first line treatment in orthostatic hypotension
· Can appear to be very similar to a seizure to an observer
· Can happen on turning the head
· Postural hypotension can be improved by drinking cold water
· Orthostatic hypotension is defined as a drop of BP >20/10mmHg within three minutes of standing
.The definition also includes the presence of symptoms of syncope or presyncope.
· Midodrine is a useful first line treatment in orthostatic hypotension
.Only occasionally used for adults with severe orthostatic hypotension due to autonomic dysfunction when corrective factors have been ruled out and other forms of treatment are inadequate. It costs £126.08 per month at maintenance dose (2017).
· Can appear to be very similar to a seizure to an observer
.Correct answer.
Both can involve transient loss of consciousness and jerking movements
· Can happen on turning the head
.Correct answer.
Carotid sinus hypersensitivity occurs when rotating the head e.g. whilst shaving
· Postural hypotension can be improved by drinking cold water
.Correct answer.
It can also be helped by drinking up to 5 caffeinated drinks per day, increasing salt ingestion and leg compression stockings grade 1 full length – but remember to check foot pulses first.
Indicate which of the following statements are TRUE in relation to Anorexia Nervosa
· The SCOFF questionnaire is a useful screening tool
· For a diagnosis to be made there must have been amenorrhoea for three months or longer
· In adults a defining feature is a BMI ≤ 16.9kg/m2
· Feeding against the will of the patient cannot be undertaken
· The SCOFF questionnaire is a useful screening tool
.Correct answer.
Explore further if 2 or more answered positively:
Do you ever make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a three-month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?
· For a diagnosis to be made there must have been amenorrhoea for three months or longer
.This criterion was no longer included when the classification was updated to DSM-5.
· In adults a defining feature is a BMI ≤ 16.9kg/m2
.The BMI is below 17.5kg/m2
· Feeding against the will of the patient cannot be undertaken
.This is a highly complex area requiring specialist medical and legal input and should only be done in the context of the Mental Health Act 1983 or Children Act 1989.
Indicate which of the following statements are TRUE in relation to Meniere's disease. (Select THREE)
· People with Meniere’s disease are not permitted to drive
· There is no cure for Meniere’s disease
· A physiotherapist can help with rehabilitation
· It can be treated with injections to the ear
· People with Meniere’s disease are not permitted to drive
.People must comply with the law by notifying the DVLA and their insurer. Providing it does not give rise to ‘sudden and disabling attacks of vertigo’ people can continue to drive. Large Goods Vehicles and Passenger Carrying Vehicles are subject to stricter rules.
· There is no cure for Meniere’s disease
.Correct answer.
Treatments aim to control or minimise symptoms
· A physiotherapist can help with rehabilitation
.Correct answer.
Vestibular Rehabilitation Therapy (VRT) helps people to cope with the disorientating signals coming from the inner ear using alternative signals from your eyes, limbs and joints.
· It can be treated with injections to the ear
.Correct answer.
In severe cases selectively destructive surgery is done using gentamicin injected through the tympanic membrane to damage the labyrinth; however there is a risk it could also damage hearing so it tends to be for people who have poor hearing already.
Indicate which of the following statements are TRUE in relation to Substance Misuse. (Select THREE)
· In people dependent on alcohol it is not advisable to tell them to stop drinking
· Some body builders abuse insulin to boost their muscle mass.
· Korsakoff's syndrome is a condition that is reversible with thiamine supplements
· Is a risk factor for suicide
In people dependent on alcohol it is not advisable to tell them to stop drinking
.Correct answer.
Stopping drinking suddenly can precipitate severe withdrawal symptoms and seizures. The best advice is to start reducing alcohol intake gradually and under specialist supervision.
· Some body builders abuse insulin to boost their muscle mass.
.Correct answer.
They may also be abusing anabolic steroids. Teenage girls with diabetes also are known to abuse insulin by omitting doses to control body weight
· Korsakoff's syndrome is a condition that is reversible with thiamine supplements
.Wernicke's encephalopathy is reversible but if it remains untreated it can become irreversible brain damage called Korsakoff's syndrome.
· Is a risk factor for suicide
.Correct answer.
Self-medicating with drugs or alcohol for anxiety in conditions like PTSD is risky behaviour and may contribute to impulsiveness.
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