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’. Post your answers below!
Case: 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?’
What is he about to tell you?
What is the diagnosis?
Share your ideas in the comments box below on what the explanation could be and what action you would take.
Getting some backache and possibly symptoms into legs.
? AAA
lost some co-ordination
–cerebellar CVA – Posterior inferior cerebellar artery
Is he going to tell me that he has also noted black stools? GI haemorrhage due to OTC NSAIDs??
Looking at the large glass of whisky in his hand in the middle of the day, I’d go with you CS and say GI bleed.
He has passed a black motion this morning leading to a diagnosis of a GI bleed.
Agree with Christoph Schultz
Black offensive stools, caused by GI bleeding, caused by OTC ibuprofen.
He has a numb arm for 5 mins which did then resolve.
That he had a numb arm for 5 mins that did then resolve.
My stools have gone black?
GI bleed secondary to NSAID use.
If so, urgent referral