Physician's Assistant

Refined clerking Sat 21 February 2026 19:13

Last Modified: 44 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Persistent dizziness

History of Presenting Complaint:
This 25 year old man presents with persistent dizziness since October 2025. He describes the sensation as struggling to focus constantly, feeling off balance like being on a boat rather than true vertigo with room spinning. He reports feeling like he has had a couple of pints all the time and cannot get steady or feel sharp. The symptoms fluctuate in severity with some days worse than others but are constantly present. He notices symptoms less when busy at work but by end of day feels exhausted.

Associated symptoms include difficulty concentrating, feeling glazed over, and episodic blurred vision despite normal optometry review showing 20/20 vision. He experiences intermittent headaches but these do not consistently accompany the dizziness. Reports feeling constantly tired and drained since symptom onset. He has noticed occasional coordination difficulties, particularly feeling backwards when on stepladders at work, though has not fallen. No palpitations reported. Describes occasional inner ear itchiness but no hearing changes.

He lives alone in a flat in Brixham, moved out in July 2025. Works as an electrician. No clear precipitant identified for symptom onset in October.

Had previous significant head injury in motor vehicle collision (rear-ended by van) with documented post-concussion syndrome affecting memory, though current symptoms described as completely different presentation.

Social History:
Lives alone in flat in Brixham, moved out from his parents July 2025. 
Occupation: Electrician involving work at heights on ladders and roofs.

On Examination:
General Appearance: Alert, appears fatigued
• Neurological Examination:
  - Cranial Nerves: Visual fields full to confrontation bilaterally. Pupils reactive. Eye movements full with no nystagmus noted on extreme gaze testing. Facial sensation intact bilaterally. Facial movements symmetrical. Hearing intact bilaterally.
  - Coordination: Finger-nose testing normal, no pathological nystagmus.
  - Gait: Heel-to-toe walking performed adequately.
  - Romberg test: Normal
  - Upper and lower limb examination: Normal tone and power
No murmurs.

Investigations:
• CRP: 1
• Hb: 157
• Eosinophils: Normal
• LFTs: Normal
• Folate: Normal
• B12: Normal
• Calcium: Normal
• Phosphate: Normal
• Magnesium: Normal
• TSH (December 2025): Normal
• ECG: Incomplete right bundle branch block (normal variant)
• CT Head: Normal, no acute intracranial pathology

Impression:
Persistent dizziness of unclear aetiology since October 2025

Differential Diagnoses:
1. Central cause (posterior circulation ischaemia/small vessel disease) - supported by abnormal head impulse test suggesting central rather than peripheral vestibular pathology, though age makes stroke unlikely
2. Post-concussive syndrome (though patient reports symptoms distinctly different from previous head injury effects)
3. Vestibular pathology (inner ear disorder, BPPV) - less likely given head impulse test findings

Management Plan:
1. Urgent Outpatient MRI Head
2. Home with trial of prochlorperazine

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Summary:

Investigations:

Tasks

Feedback

• Good rapport building and comprehensive neurological examination demonstrating systematic approach to dizziness presentation
• Excellent explanation of investigation rationale (CT vs MRI, central vs peripheral causes) using patient-friendly language - particularly good analogy explaining incomplete right bundle branch block
• Strong safety-netting with clear plan for rapid access imaging and alternative pathway if radiologist declines direct MRI
• Consider exploring occupational health impact more thoroughly given significant safety concerns working at heights as electrician - may need temporary work restrictions
• Missed opportunity to specifically assess for orthostatic hypotension given diabetes history - lying/standing BP would be valuable
• Family history taken but impact on patient anxiety not explored - mother with multiple genetic conditions may be contributing to health anxiety
• Could have explored symptom diary/pattern recording more systematically to identify triggers (time of day, position changes, specific activities)
• Red flag screening appropriate but could have been more explicit about when to re-attend (new focal neurology, sudden worsening, falls)
• Excellent management of patient expectations regarding investigation timeframes and consultant involvement