A patient says they feel "dizzy". What is the single most useful first question? ANSWER: ask them to DESCRIBE the sensation WITHOUT USING THE WORD "DIZZY". WHY: the word covers FOUR different symptoms with different causes. VERTIGO an ILLUSION OF MOVEMENT — the room spins → vestibular system or its central connections PRESYNCOPE about to faint → CARDIOVASCULAR: postural drop, arrhythmia, anaemia, bleeding DISEQUILIBRIUM unsteady on the feet, worse in the dark → neurological, visual or musculoskeletal LIGHT-HEADEDNESS vague; anxiety and hyperventilation contribute Forcing a DESCRIPTION rather than a label separates these more reliably than any list of follow-up questions. "The room went round" and "I felt I was going to drop" lead to completely different assessments.

A 70-year-old has severe vertigo with vomiting. Which single bedside test best distinguishes a central from a peripheral cause? ANSWER: ASK THEM TO WALK. PERIPHERAL vertigo — the patient STAGGERS but can usually walk with support. CENTRAL lesion — the patient often CANNOT stand or walk at all. WHY THIS TEST RATHER THAN IMPRESSION: SEVERITY DOES NOT DISCRIMINATE. Peripheral vertigo is frequently the MORE dramatic presentation — the patient vomits, cannot open their eyes and looks profoundly unwell — while a posterior circulation stroke may look comparatively unimpressive. Judging by how ill the patient appears on the trolley gets this BACKWARDS. OTHER CENTRAL FEATURES: double vision, slurred speech, swallowing difficulty, limb weakness or numbness, new severe headache, and a first attack in an older patient with vascular risk factors.

A patient has brief attacks of spinning triggered by rolling over in bed, settling when they stay still. Hearing is normal. What is the likely diagnosis, and what feature is most diagnostic? ANSWER: benign POSITIONAL vertigo. The most diagnostic feature is the POSITIONAL TRIGGER. Brief attacks · provoked by a CHANGE OF HEAD POSITION · settling when still · NORMAL hearing. CONTRAST WITH THE OTHER PERIPHERAL PATTERNS: Longer episodes WITH hearing loss, tinnitus and ear fullness, hearing fluctuating between attacks. A SINGLE PROLONGED attack over days, often after a viral illness, gradually settling as the brain compensates. DURATION AND HEARING TOGETHER sort most peripheral vertigo. NOTE: no durations in minutes are given here deliberately — they overlap between conditions more than textbook summaries suggest, and a patient outside a memorised range should not be reclassified because of it.

A 58-year-old smoker has a hard, painless neck lump present for two months. What must you do, and what must you NOT do? MUST DO: 1. Treat it as MALIGNANCY until proven otherwise — persistent, painless, hard or fixed in an adult. 2. LOOK IN THE MOUTH AND THROAT. A neck node can be the FIRST sign of a head and neck primary in the tongue base, tonsil, nose or larynx. 3. Ask about TOBACCO, BETEL QUID and ALCOHOL. 4. Refer for specialist assessment and needle sampling. MUST NOT DO: EXCISE IT to find out what it is. WHY NOT: if the node is malignant, an open biopsy disturbs tissue planes and can COMPROMISE THE DEFINITIVE OPERATION that follows — potentially worsening the outcome for a patient whose disease was curable. Find the primary FIRST; sample with a needle. ALSO CONSIDER: tuberculosis, an important cause in Nepal, and lymphoma — especially with fever, weight loss or night sweats.

A midline neck lump moves upwards when the patient sticks out their tongue. What is it? ANSWER: a THYROGLOSSAL CYST. It is tethered along its embryological tract, which runs up toward the tongue base — so tongue protrusion pulls it upward. CONTRAST: A lump that moves on SWALLOWING is attached to the larynx and trachea → THYROID. Both tests take seconds, need no equipment, and localise a midline lump before any imaging.

An 80-year-old on several medications complains of dizziness. What should be considered before a vestibular assessment? ANSWER: a MEDICATION REVIEW. Antihypertensives, sedatives, antidepressants and anticholinergics all cause dizziness, and POLYPHARMACY compounds the effect. In an older patient this is frequently more productive than a vestibular assessment, and it connects directly to the falls and polypharmacy chapter — dizziness contributes to falls, and falls in the elderly cause fractures and loss of independence. ALSO ESTABLISH WHICH SYMPTOM: an elderly patient describing dizziness on standing is describing PRESYNCOPE, which is a cardiovascular problem (postural drop, arrhythmia, anaemia, dehydration) — not vertigo, and not a vestibular question at all.

A patient reports tinnitus in ONE ear only. Is this the same as ordinary tinnitus? ANSWER: No. UNILATERAL or PULSATILE tinnitus needs explaining rather than reassuring. BILATERAL tinnitus with symmetrical hearing loss is common and usually benign. UNILATERAL tinnitus, or tinnitus that beats IN TIME WITH THE PULSE, requires investigation. This is the same principle as UNILATERAL hearing loss in the ENT chapter: the auditory system is a paired, symmetrical structure, so an asymmetrical symptom implies a localised cause and demands an explanation. Symmetry is reassuring; asymmetry is not.