Trainee Advanced Clinical Practitioner Diary- Day 8 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 8

Labyrinthitis, TIMI risk scoring, GALS screening.


Patient presented with sudden onset dizziness whilst watching TV.

The labyrinth is made up of fluid filled channels which control balance and hearing. Movement of the head causes the fluid in those channels to move, which is detected by the hair bundles in the ear and interpreted by the brain.



labyrinthAn infection in one ear or the other can cause a disturbance in this mechanism which can lead to vertigo.

Symptoms can include:

  • A spinning feeling even when still (vertigo).
  • Nystagmus.
  • Dizziness.
  • Unilateral hearing loss.
  • Nausea and/or vomiting.
  • Tinnitus.

Treatment can include:

  • Antihistamines
  • Medicines to control nausea and vomiting, such as prochlorperazine.


  • Stay still and rest.
  • Avoid sudden movements or position changes.
  • Slowly resume activity. You may need help walking when losing balance during attacks.
  • Avoid bright lights, TV, and reading during attacks. Rest during severe episodes, and slowly increase activity.

Differential diagnosis for dizziness (VITAMIN C)


-Orthostatic hypotension

-Cardiac arrhythmias, valve stenosis

-Brainstem cerebrovascular disease



-Labyrinthitis – postviral






-Thyroid disease






-Cerebellopontine Angle Tumors (Vestibular schwannoma)




-Medication side effects


Otologic (Vestibular) causes

-Benign Paroxysmal Positional Vertigo (BPPV)

-Meniere’s disease

TIMI risk scoring categorises a patients risk of death and ischeamic events. Helps with decision making process as to patients pathway.




Age > 65
Markers (increased serum cardiac markers)
EKG (ST depression)
Risk factors (3 or more CAD risk factors: patient age (>45 M, > 55 F), family history [CAD in first degree relatives, <55 M, <65 F), hypercholesterolemia, hypertension, smoking, diabetes, obesity, sedentary lifestyle, metabolic syndrome)
Ischemia (2 or more anginal events over past 24 hours)
CAD (prior coronary stenosis of 50% or more)
Aspirin use within past 7 days

Application of the TIMI Risk Score for Unstable Angina and Non-ST Elevation Acute Coronary Syndrome to an Unselected Emergency Department Chest Pain Population. Academic Emergency Medicine 2008

Musculoskeletal GALS screen

Begin by asking 3 screening questions.
• Have you any pain or stiffness in your muscles, joints or back?
• Can you dress yourself completely without any difficulty?
• Can you walk up and down stairs without any difficulty?
Next examine the patient as documented below. Remember to get the patient to copy
you and compare one side with the other.
• Ask the patient to walk a few steps, turn and walk back. Observe gait for symmetry,
smoothness and ability to turn quickly.
• Stand patient. Inspect from behind, from side and in front. Look for bulk and
symmetry of shoulder, gluteal, quadriceps and calf muscles; limb alignment,
alignment of spine; level iliac crests; ability to fully extend elbows and knees; popliteal
swelling; abnormalities of feet.

• Ask patient to put their hands behind their head. Assess shoulder abduction and
external rotation and elbow flexion.
• With patient’s hands held out, palms down, fingers outstretched, observe the back of
the hands for joint swelling and deformity.
• Ask patient to turn their hands over. Look for muscle bulk and deformities.
• Ask patient to make a fist. Visually assess power grip, hand and wrist function and
range of movement in fingers.
• Ask patient to squeeze your fingers.
• Ask patient to bring each finger in turn to meet the thumb. Assess fine precision
• Gently squeeze MCP joints for tenderness (ask about pain first).

• While standing inspect from the front, side and behind paying special attention to the
popliteal fossa.
• Lie patient on couch. Assess full flexion and extension of both knees, feeling for
• With hip flexed to 90 degrees, holding the knee and ankle, assess internal rotation of
each hip in flexion.
• Perform a patellar tap.
• Squeeze across MTP joints (ask about pain first).
• From end of bed inspect feet for swelling deformity and callosities.

• From behind inspect the spine for scoliosis
• From the side inspect spine for lordosis and kyphosis
• Ask patient to touch their toes. Assess lumbar spine flexion by placing two fingers on
the lumbar vertebrae. Your fingers should move apart on flexion.
• Inspect lateral cervical flexion by asking the patient to put ‘their ear to their shoulder’
on each side.

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