The case

A 75-year-old man presented to the emergency department with dizziness. He had been in good health until 5 weeks before admission, when his ladder slipped while he was cutting branches in a tree. He fell on to his upper back and left shoulder but did not hit his head or lose consciousness. Following the fall, he developed persisting left-sided neck and shoulder pain. A chiropractor manipulated his neck six times without significant relief. On the day of admission, he became non-specifically unwell following his morning walk and went to lie down. On getting up he felt extremely dizzy, both spinning and light-headed. He lay down but remained unwell, with shortness of breath and chest discomfort. The symptoms completely resolved in less than 5 min. He came to the emergency department by ambulance.

There was no past history or specific risk factors for vascular disease and he took no regular medications.

On examination, his blood pressure was 170/80 mm Hg but other vital signs were normal. The emergency department registrar documented normal cardiovascular, respiratory and abdominal examinations, with no spinal tenderness or neck movement restriction. Neurological examination was normal, including eye movements, coordination and gait.

Comment

The symptoms are non-specific and the differential diagnosis is wide. Routine blood tests can help to exclude dehydration, metabolic disturbances or infection. A 12-lead ECG, cardiac enzymes and a period of cardiac monitoring can help to exclude cardiac ischaemia or an arrhythmia. Although dizziness is non-specific, the lack of improvement with lying down argues against simple presyncope. Further neurological assessment with a Dix–Hallpike manoeuvre and head impulse test might help. The symptoms in isolation probably do not warrant neuroimaging; however, the neck pain following trauma and subsequent chiropractic manipulation raise the possibility of vertebral artery dissection, and the need for MR scan of …