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Background: Differential diagnosis of acute vertigo syndrome is challenging given the similarities between clinical presentations of posterior circulation stroke and peripheral vestibular dysfunction. The Head Impulse, Nystagmus, Test of Skew ('HINTS') assessment is a clinical bedside test used to aid diagnosis., Methods: Comprehensive training on use of the Head Impulse, Nystagmus, Test of Skew assessment was provided to one stroke consultant, and the effectiveness of the test in that setting was assessed. Further education was completed with more members of the stroke and emergency department multi-disciplinary team. Quality improvement measures including magnetic resonance imaging use and bed utilisation were explored., Results: Following training of one stroke consultant, the Head Impulse, Nystagmus, Test of Skew assessment was found to be a feasible, accurate bedside test within this acute stroke service. Further training for the multi-disciplinary team was completed, but outcome measures were not explored because of the coronavirus disease 2019 pandemic and maternity leave., Conclusion: There is a role for trained members of the multi-disciplinary team to successfully use the Head Impulse, Nystagmus, Test of Skew assessment in hyperacute stroke settings, to aid diagnosis in acute vertigo syndrome.

A 71-year-old woman, who had been taking lansoprazole for 18 months for dyspepsia, presented with vomiting, thought to be due to gallstones, and was found to have severe hypomagnesaemia. She was treated with intravenous and then oral magnesium, and discharged, but was soon readmitted with symptoms due to hypomagnesaemia, and again treated with magnesium supplementation. No other recognised cause for hypomagnesaemia was found. Because of recent reports of hypomagnesaemia due to other proton pump inhibitors, lansoprazole was changed to ranitidine. Her symptoms resolved and the serum magnesium returned to normal. Oral magnesium supplementation was stopped with no return of symptoms or hypomagnesaemia. Such an association must be borne in mind with suggestive symptoms in patients on long term proton pump inhibitors; their cessation or change to H(2) receptor antagonists is likely to correct the situation rapidly.