Yesterday was the beginning of my 2nd week posting of my Primary Care Medicine and i've clerk one patient with a c/0 of dizziness. Ususally, i'll be given an hour to clerk. because i got this patient late, i have such a short time to clerk this patient. Patient is 38 malay lady works as a kindergarden teacher. She complaint of having dizziness for the past two weeks that are worsoning. However the dizziness have been there for the past 5 years already. But this time it was the worst and not relief by medication. At first i was thinking of Benign positional proxysmal vertigo (BPPV).
As a typical noob medical student, when we have a target, we cant think of other disease. I do manage to think other disease such as anaemia causing vertigo.
Time up! owh damn. i havent finish clerking and i didn't manage to do any of physical examination. my lecturer ask me to present the case. So as usual, i present in the way that i usually present. (haha). Dr ask me what the diagnosis. So i tell her the BPP
HistoryDid you ask about anaemia? Did u ask about other things apart from lethargy, SOB etc? Owh damn... i forgot and blank.. then i ask what dr? lolz.... we shouldn't ask like that! kene lagi!
You need to ask about menstrual hx. Do u ask that? Do u ask about any cause of anaemia? Do u ask anything about bruises, jaundice, diet hx, etc2.. owh then i got it.. it's just the cause of anaemia.. Lolz. Of course i knew it, but then again, i cant relate it with the hx i take.. how pathetic..
Then the dr ask the patient to come in. This time dr take the 'proper hx'. The patient claim that she's having it since the day she delivered her last child. It was also associated with tremor, palpitation. and she said it again and again. She claim the dizziness also come during when she needs to see the principle, or need to get infront giving speech to the students. So what do u think the diagnosis now? Hehe.. wait till the end of the post..
So we do the maneuver to detect nystagmus to rull out BPPV, we do CVS also. But we didnt do any CNS examination. At the beginning, i was shock, but deeply in my heart saying thank god that the lecturer didn't ask me to do the worst examination ever - CRANIAL NERVE EXAMINATION.. haha.. Anyway we make it simple, dr have the diagnosis already. The lect says 'u all should think of Psychosocial also u know'. Immediately i think, what on earth vertigo related to psychosocial. So i took my oxford handbook and got to my vertigo page. (7th edition page 454). Now i know that vertigo can be true and false! aiyooo.. Oxford says, what is not vertigo is faintness may be describe as dizziness but often due to anxiety with associated palpitation, tremor and sweating. lolz.. i've study for 2 years and i still didn't know that vertigo(i meant dizziness) can be due to anxiety!! HAHAHA.. That's might be the case that i need to study extra 6 months..
Just forget about it, it's happening already. So the diagnosis was Panic Disorder and we managed her by doing FBC, thyroid function test, and gave her anxiolytics which is benzodiazepine. Because my lecturer was so afraid of giving this drug due to the SE (addicted) she only dare to give her the drug for 3 days, lolz... Nevermind then, a psychiatric will give her more.. muahaha..
So in summary, dont think that vertigo is just due to the inner ear problems only. think generally such as anaemia, heart disease, thyroid and put the tumour at the last last last last part of differentials or the best is dont ever say it and try think of psychiatric.. hehehehe..
Just want to share some readings materials in the web about anxiety. Nice to read, really. The site shows ways to tackle your anxiety. http://www.treatment-for-anxiety.org/
Till we meet next time, nite..