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Internal Medicine > Dizziness > Flashcards

Flashcards in Dizziness Deck (27):
1

What symptoms may a patient experience which they call dizziness (4)

Vertigo
Lightheadedness
Syncope
Imbalance

2

Most common causes of vertigo (3)

Migraine-related
BPPV
Meniere's

3

Categories of etiology

Vestibular
Neurological
Cardiovascular
Psychological
Metabolic
Autoimmune
Drug related
Trauma/surgical
Infectious

4

Vestibular causes (7)

1. Benign paroxysmal positional vertigo
2. Meniere's->episodic, fluct hearing loss, tinnitis, aural pressure/fullness
3. Temporal bone fracture, hypothyroid (hydrops), syphillis
4. Labrynthitis->URTI
5. Superior semi-circular canal dishiscience
6. Perilymphatic fistula
7. Middle ear->OM, labrynthitis

5

Neurological causes

Migraine related->history of migraines
Posterior fossa tumors->vestibular scwannomas, meningiomas
Multiple sclerosis->prolonged, spontaneous
Cerebellar stroke
Vertebrobasilar stroke
Wallenberg
Hereditary ataxias
BIH
Normal pressure hydrocephalus

6

How does vertebrobassilar stroke present

episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities.

7

Clinical features of BIH->pseudotumor cerebri

raised intracranial pressure that is not caused by a mass lesion (e.g., a tumour); associated with headache and transient poor vision. These patients are often obese and complain of clumsiness, imbalance, and dizziness rather than true vertigo.

8

How does normal pressure hydrocephalus present

Ataxia
Urinary incontinence
Cognitive dysfunction

9

Cardiovascular causes

Syncope
Presyncope
Orthostatic hypotension
Autonomic dysregulation

10

Psychological

Psychophysiological->after labrynthe disorder
Psychogenic->agoraphobia, personality, anxiety

11

Metabolic causes

Diabetes->hypoglycemia
Hypothyroidism->+in patient's with meniere's

12

Autoimmune causes

Rheumatoid arthritis
Systemic lupu erythromatosous
Wegener's
Bechet's

13

Medication induced

Ototoxic drugs: gentamycin, neomycin
Chemotherapeutic->cisplatin
Alcohol
AntiHTN, anesthetic, antiarrythmia

14

Risk factors for medication induced

age >60 years, high serum drug levels, previous sensorineural hearing loss, concomitant renal impairment, attendant noise exposure, duration of therapy >10 days, and simultaneous administration of other ototoxic agents, such as loop diuretics or aspirin

15

Trauma causes

Post head injury
Complication of middle-ear surgery

16

Infectious causes

Lyme disease
Syphillis
CMV
HSV-1
HIV

17

Red flags

Red flags
Meniere's disease
Vestibular neuritis
Syncope or presyncope
Labyrinthitis
Cholesteatoma
Posterior fossa tumour
Multiple sclerosis
Cerebellar stroke
Vertebrobasilar insufficiency
Wallenberg's syndrome
Paraneoplastic cerebellar degeneration
Lyme disease
Syphilis
HIV

18

History- charactristics of current episode

Dizziness, vertigo or syncope
Vertigo better or worse with eyes closed/open (more central does not change)
Duration: seconds (BPPV), mins-hours (migraine, meniere's, CV), hours-days (labrynthitis, neuritis, central)
Positional
Tinnitus or hearing loss: meniere's, labrynthitis (sudden hearing loss, NV), MS, SLE, infections
How the episodes began: URTI, trauma, surgery
General symptoms
-chest pain, exertiona dyspnea
-aura, visual disturbance, photo/phonophobia, headache
-nausea
-gait, limb weakness, dysarthria
-diplopia, dysarthria, ataxia, drop
-ataxia, urinary, cognitive
-clumsy, imbalance, dizziness
Psychiatric

19

History- identification of a cause

Trauma/surgery
Medical illness-> DM, thyroid, MS, migraines
FHx of illness->migraine, ataxias
Contact with infectious
Medication and drugs
CVD risk factors
Neoplastic disease

20

Physical examination

1. Ear examination
2. Eye: nystagmus, movements (palsies in MS, ICL), neurological signs (central)
3. Clinical balance tests
- Head impulse test->differentiates acute vestibular neuritis, cerebellar stroke
-Dix-hallpike
4. CNS
-Cranial nerves
-cerebellar
-Gait
-Rombergs
-Limbs
-Speech
5. Cardiovascular

21

What is the head impulse test

The examiner turns the patient's head as rapidly as possible 15 degrees to one side and observes the patient's ability to keep fixating on a distant target. With a peripheral vestibular lesion, a saccade occurs as the vestibulo-ocular reflex fails, the patient cannot keep focusing on the target, and a catch-up movement occurs. After a cerebellar stroke, no catch-up saccade occurs. The head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting) in people with cerebellar stroke, ruling out acute vestibular neuritis or labyrinthitis.

22

Describe the dix-hallpike

The test is performed by sitting the patient upright on a bed; for the right side, the examiner stands on the patient’s right side, rotates the patient’s head 45° to the right, and then moves the patient, whose eyes are open, to the supine right-ear down position, and then extends the patient’s neck slightly so that the chin points slightly upwards. Patient's symptoms are noted and any nystagmus is observed

23

Results in dix hallpike if central lesion

test causes nystagmus that is not fatigable, is down-beating, and is associated with minimal vertigo.

24

What is the supine roll test and when is it performed

If the Dix-Hallpike test is negative in a patient who has a history suggestive of BPPV

positioning the patient supine with the head in the neutral position, then quickly rotating the head 90° to one side -->?nystagmus.
The head is returned to the face up position, allowing all dizziness and nystagmus to subside; the head is then turned rapidly to the opposite side

25

Findings in wallenbergs (5)

occlusion of the ipsilateral vertebral artery that supplies the posterior inferior cerebellar artery) causes:
1. prolonged vertigo,
2. abnormal eye movements,
3. ipsilateral Horner's syndrome,
4. ipsilateral limb ataxia, and
5. loss of pain and temperature sensation of the ipsilateral face and contralateral trunk

26

Investigations and findings

1. Audiogram
2. CT->if suspect SSCD
3. MRI->posterior fossa tumor, cerebellar stroke, MS, head injury
4. ECG, echo, 24 hour holter, tilt-table
5. Special blood tests depending on history: antibodies, thyroid glucose, drug levels

27

Medications that cause orthostatic hypotension

Antihypertensives
Antidepressants
Anticholinergics