Author: Joanna Lumb / Editor: Steve Corry-Bass / Reviewer: Joanna Lumb / Codes: EP7, GP9, NeuP9, SLO1, SuP7 / Published: 20/05/2022

A woman in her 50s presents to the Emergency Department (ED) after waking at 5am with nausea and vertigo – the room was spinning horizontally, and was worse with head movements and on standing. She had no headache or meningism, no symptoms of viral or bacterial infection, and had no other neurological symptoms apart from feeling off-balance and unsteady on her feet.

She has a past medical history of shoulder pain, and has no regular medications. She does not drink or smoke, lives alone, and is a shop-owner.

On examination, observations are normal and she has no neurological signs apart from diplopia at the extremes of eye movements. ENT examination is also normal. A HINTS examination is also performed.

Her ECG shows normal sinus rhythm, and her bloods are unremarkable.