Dizziness

Question 1

What are the common side effects of opiates?

Answer 1

• N&V
• Itch
• Constipation

Question 2

What systems review questions do you want to ask in history of dizziness?

Answer 2

• Cardiorespiratory: SOB, palpitations, chest pain, N&V, cough/productive cough
• GI: change in bowel movements, N&V, blood in stools, abdominal pain
• Neurological: headaches, visual/hearing problems, tinnitus, facial drooping, limb weakness, speech difficulty
• Thyroid: hot, sweating, anxious, menstrual irregularities, diarrhoea
• Generally feeling well - fever/infection
• Rec drug use can contribute to dizziness

Question 3

What can help with constipation?

Answer 3

• Rest feet on a low stool when opening bowels
• Increased physical activity, fruit, vegetable, fibre and whole grain intake
• Fruits high in sorbitol include apples, apricots, grapes (and raisins), peaches, pears, plums, strawberries and raspberries

Question 4

What tests could be done to investigate dizziness?

Answer 4

• FBC: anaemia
• U&Es: electrolyte imbalances
• TFTs: thyroid disorders
• ECG or 24hr ECG: cardiac cause - more likely if there is palpitations and SOB alongside the dizziness

Question 5

What are the red flags for ear problems?

Answer 5

• Unilateral tinnitus: important to exclude acoustic neuroma by referring to ENT for MRI
• Sudden, complete unilateral hearing loss with vertigo: suggest acute ischaemic episode (i.e. posterior cerebellar artery thrombosis) and requires immediate secondary care assessment
• Young/middle aged patient who has atypical episodic vertigo with other transient neurological symptoms - consider MS

Question 6

What is the test and treatment for BPPV?

Answer 6

• Perform Dix-Hallpike test, positive predictive value is 83%, with negative predictive value of 52%
• Epley manoeuvre - instant relief in 80% of cases, can also teach patient exercises to do at home (vestibular rehabilitation) e.g. Brandt-Daroff exercises

Question 7

Why would an audiogram be done in dizziness?

Answer 7

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, can be referred depending on occupation e.g. rock band player.

Question 8

What can you advise the patient to do after trying to treat BPPV?

Answer 8

• Be careful with bending and moving their head up and down
• Advise that they try to sleep at a 45% angle for the next couple of nights
• Try to maintain horizontal movement of the head to prevent neck stiffness.

Question 9

What is a useful test to do in GP?

Answer 9

Lying and standing BP - check BP lying then after standing at intervals of 1, 3 and 5 mins. Also need to ask for symptoms if assessing for postural hypotension.

Question 10

What are other considerations if a patient presents with anxiety/baggy clothing?

Answer 10

• Anxiety: inappropriate clothing or poor hygiene could indicate psychosis, mania or depression and is part of the MSE.
• Eating disorder: to diagnose anorexia nervosa, BMI needs to be <17.5kg/m^2 but there are other EDs where the BMI may not be low (poor feeding/dehydration can cause dizziness/weakness)
• Hyperthyroidism: weight loss may indicate this, can cause symptoms similar to anxiety
• Safeguarding concern: the GP could be alerted to this with clothes that are ill-fitting, particularly in a younger child where neglect might be the cause. The relationship with the parent would also be assessed in this situation and any clues the young person may give.

Question 11

What would you do if there is anxiety presenting in children?

Answer 11

Do a thorough assessment and history and consideration of any safeguarding issues. If there were any concerns, then this should be discussed with the safeguarding lead at the practice and referred on to social services (or the police if there was a high level of concern). Parental or carer consent is not required to refer to social services, but a referral should ideally be discussed with the parent or carer first, unless it is against the child’s best interests to do so.

Question 12

What is the National Association of School Nurses (NASN) and what are their duties?

Answer 12

Defines school nursing as a specialised nursing practice that advances the wellbeing, academic success, lifelong achievement, and overall health of students. Their duties 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
• working closely with others, including GPs and social services, in child protection cases where required

Question 13

What must you rule out for a potential seizure in a history of dizziness?

Answer 13

• Jerking movements or rolling back of eyes into their head
• Tongue biting
• Incontinence/uncontrolled bowel movement
• Ask if there were eyewitnesses

Question 14

How accurate are home pregnancy tests?

Answer 14

~97% accurate when done on the day of the 1st missed period. GP surgeries use similar tests.

Question 15

What medications could help with vertigo?

Answer 15

• Vestibular sedative such as cyclizine, cinnarzine or prochlorperazine
• Vasodilator in the inner ear called Betahistine