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Case of the month answers: Did you get what caused the non-vertigo dizziness?

Case of the month answers: Did you get what caused the non-vertigo dizziness?

In the second of a new monthly series, we are asking readers to help solve this case involving a 67-year-old man who has dizziness and an ‘odd thing he has noticed today’. Find the answers below!

You are the duty doctor on an interminable-feeling shift full of all the usual coughs, sore throats and febrile children. You notice that the next patient on your list is a 67-year-old man whose complaint, according to the note made by the receptionist, is ‘Dizziness’. This strikes you as slightly odd given that all these cases are supposed to be ‘urgent’.

Your best guess prior to ushering him in is that he will be suffering acute vertigo – assuming this is a genuinely acute case. He rises fairly slowly from the chair in the waiting area but walks without trouble to your consulting room.

The story is that he is usually fit and well but today, for the last few hours, has felt very dizzy. By this he means light headed, particularly on standing – but there is no illusion of movement and no nausea or vomiting. He has never experienced this before.

Prior to this, he has been perfectly fit and well, apart from some minor aches and pains from work he has been doing in his garden and for which he’s just take over the counter painkillers. ‘I really don’t like to bother you doctors,’ he says, a statement borne out by his records, which reveal that he has nothing of relevance in his past history, is on no repeat medication and has attended a total of two times in the last ten years. ‘I only came because my wife insisted’.

He volunteers no other symptoms today and in particular, on questioning has had no chest or abdominal pain, nor any neurological symptoms. 

On examination he looks well enough. The findings are:

  • HR 112 regular
  • BP 110/70 with a minimal drop on standing (and no old readings to compare)
  • P02 98%
  • Heart sounds normal

Perplexed, and going by your gut instinct, you ask the HCA to do an urgent ECG while you see another patient. When he comes back in he says the light headedness is still there. The ECG is completely normal, apart from the previously noted tachycardia and, as you ponder what to do next, he says, ‘I doubt it can be of any relevance, but there is one odd thing I’ve noticed today, if that helps?’

Answer

He is about to tell you that he has noticed his stool has been black today. This is because he has had an acute upper gastrointestinal bleed – which is the cause of his dizziness.

There are some clues in the case:

  • Non-vertigo dizziness may be a bit of a heartsink symptom when seen in routine surgery as it is often longstanding and often difficult to pin down. But it is very unusual if of genuinely acute onset and should therefore ring some alarm bells.
  • He has been taking some ‘over-the-counter painkillers’ for gardening-related aches and pains. These turn out to be NSAIDs, which are associated with upper GI bleeds – which can be painless.
  • His tachycardia and lowish blood pressure certainly suggest something is going on, and a bleed would be one of those ‘somethings’ – another potential cause would be a silent myocardial infarct. The normal ECG does not rule this out, of course, but makes it less likely.
  • Wives know their husbands. Take wifely concern seriously.

He was admitted to hospital, made a full recovery, and was left wondering what all the fuss was about.


          

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