Dizziness, Vertigo, Syncope, and Seizures

Question 1

What are the three major causes of dizziness

Answer 1

• Presyncope (lightheadedness)
• Vertigo
• Multisensory stimuli - Grand canyon or hearing shocking news

Question 2

What sensation does patient experience in vertigo

Answer 2

Room spinning

Question 3

What is the initial thing you must do when a patient presents with vertigo

Answer 3

See if it is peripheral (benign) vs. central (serious)

Question 4

Difference in onset, intensity, and N/V intensity between central and peripheral vertigo

Answer 4

Central vertigo is gradual onset, mild intensity, mild N/V, while peripheral vertigo is sudden onset, severe intensity, severe N/V (3 S’s)

Question 5

Difference in neurological findings between peripheral and central vertigo

Answer 5

Central vertigo has associated neurological findings, while no neurologic findings in peripheral vertigo (except maybe hearing and tinnitus)

Question 6

Difference in nystagmus and position between central and peripheral vertigo

Answer 6

Central vertigo has mild nystagmus and position change has mild effect, while peripheral vertigo has severe effect from position change and severe nystagmus (2 S’s)

Nystagmus: Multidirectional and vertical in central, unilateral vertical in peripheral

Question 7

Difference in refractoriness in tilt test between central and peripheral vertigo

Answer 7

Central vertigo - no refractoriness (tilt test can be repeated)

Peripheral vertigo - rapidly refractory (tilt test cannot be repeated)

Question 8

Which way will patient fall in both central and peripheral vertigo

Answer 8

Towards side of lesion

Question 9

What are the five types of peripheral vertigo

Answer 9

1. ) Benign positional vertigo
2. ) Meniere’s disease
3. ) Acute labyrinthitis
4. ) Ototoxic drugs - aminoglycosides and diuretics
5. ) Acoustic neuroma (Shwannoma)

Question 10

Peripheral Vertigo: What are three characteristics of benign positional vertigo

Answer 10

1. ) Vertigo only experienced in specific positions, lasts for few moments
2. ) Age > 60
3. ) Recovery complete within 6 months(Rule of 6’s)

Question 11

Peripheral Vertigo: What is the treatment for benign positional vertigo

Answer 11

Meclizine

Question 12

Peripheral Vertigo: What is the triad for meniere’s disease

Answer 12

Vertigo, tinnitus, and hearing loss

Question 13

Peripheral Vertigo: Difference between benign positional vertigo spells and meniere’s disease vertigo spells

Answer 13

BPV lasts for a few moments, meniere’s lasts for hours to days and recurs several months or years later. BPV heals on own, meniere’s disease hearing loss becomes permanent

Question 14

Peripheral Vertigo: What is the treatment for meniere’s disease

Answer 14

Sodium restriction and diuretics

Question 15

Peripheral Vertigo: How does acute labyrinthitis occur

Answer 15

Viral infection of choclea and labyrinth lasting for several days

Question 16

Peripheral Vertigo: Symptoms of acoustic neuroma

Answer 16

Ataxia, gait unsteadiness, nystagmus, hearing loss, and tinnitus

Question 17

Three causes of central vertigo

Answer 17

1. ) Multiple sclerosis
2. ) Vertebrobrasilar insufficiency
3. ) Migraine-associated vertigo

Question 18

What is the definition of syncope

Answer 18

Transient loss of consciousness/postural tone secondary to acute decrease in cerebral blood flow, with rapid recovery of consciousness without resuscitation

Question 19

Two major categories to divide syncope into

Answer 19

Cardiac and non-cardiac (neurogenic)

Question 20

Cardiac syncope characteristics

Answer 20

Sudden and without prodromal symptoms i.e. patient’s face hits floor, during exercise, may be manifestation of underlying cardiac problem

Question 21

Three major causes of cardiac syncope

Answer 21

1. ) Arrhythmias
2. ) Obstruction of blood flow
   3: ) Massive MI

Question 22

Does vasovagal (neurocardiogenic) syncope have precipitating factors and premonitory symptoms?

Answer 22

Precipitating - Pain, fear, stress, extreme fatigue

Premonitory - Pallor, diaphresis, lightheadedness, nausea, dimming vision

Question 23

What physical examination is positive in a vasovagal (neurocardiogenic) syncope

Answer 23

Tilt table study - reproduces symptoms

Question 24

What age group does vasovagal (neurocardiogenic) syncope occur in?

Answer 24

Before age 40

Question 25

What is the pathophysiology of vasovagal syncope

Answer 25

Compensatory sympathetic innervation of standing up doesn't work and parasympathetic goes into overdrive

Question 26

What symptoms occur in vasovagal syncope?

Answer 26

Inappropriate bradycardia, vasodilation, marked decrease in BP, reduced cerebral perfusion (overactive parasympathetic)

Question 27

What is the reversible physical treatment and medical treatment for vasovagal syncope

Answer 27

Physical: Supine posture and elevate legs Medical: B-blockers and disopyramide

Question 28

What are three main reasons for orthostatic hypotension to occur

Answer 28

1. ) Autonomic failure (diabetes, parkinsons) 2. ) Volume depletion (diuretics, dehydration, etc) 3. ) Medications

Question 29

What is the definition of orthostatic hypotension

Answer 29

Reduction in BP due to postural change

Question 30

How do you treat orthostatic hypotension?

Answer 30

Increased sodium intake and fluids. Pharmacologic: Midodrine and fludrocortisone

Question 31

What is the main goal of diagnosing syncope in general

Answer 31

To differentiate between cardiac and noncardiac etiologies

Question 32

What are three things you must do for history when someone presents with syncope

Answer 32

1. ) Find out events around syncope event 2. ) Check medications 3. ) Ask witnesses

Question 33

What five physical examinations should you do in syncope

Answer 33

1. ) BP supine, sitting, standing 2. ) Mental status 3. ) Murmurs (aortic stenosis, hypertrophic cardio) 4. ) Carotid pulses - check bruits 5. ) Reflex bradycardia and hypotension via pressure to carotid sinus

Question 34

What labs should you order to help in the diagnosis to the type of syncope

Answer 34

ECG for sure, CBC, metabolic panel

Question 35

What additional tests can you do when someone presents with syncope

Answer 35

1. ) 24 hour holtor monitoring for arrhythmia 2. ) Table tilt - if recurrent episodes and vasovagal (non cardiac) 3. ) CT/EEG - if seizure 4. ) Echo - if ECG is abnormal or other evidence of structural heart disease

Question 36

How does a seizure occur?

Answer 36

Sudden abnormal discharge of electrical activity in the brain

Question 37

What is the definition of epilepsy?

Answer 37

Recurrent, idiopathic seizures

Question 38

Out of the eight causes of seizures, what are the four M's

Answer 38

1. ) Metabolic disturbances - hyponatremia, hypoglycemia, hypocalcemia, uremia, thyroid storm, etc 2. ) Mass lesions - cancers, hemorrhage 3. ) Missing drugs - non-compliant with anticonvulascents or acute withdrawal from alcohol, benzos, barbiturates 4. ) Miscellaneous - pseudo-seizures (aware of it), enclampsia, hypertensive encephalopathy

Question 39

Out of the eight causes of seizures, what are the four I's

Answer 39

1. ) Intoxication - cocaine, lithium, lidocaine, theophylline, carbon monoxide, metals 2. ) Infections - meningitis, abscess in brain 3. ) Ischemia - stroke, TIA 4. ) Increased ICP - caused by trauma

Question 40

What are the two major categories of seizures and the two subcategories for each

Answer 40

1. ) Partial seizure - One part of brain with temporal lobe and associated symptoms from any other part involved a. ) Simple b. ) Complex 2. ) Generalized seizure - Both parts of brain with loss of consciousness a. ) Tonic clonic (grand mal) b. ) Absence

Question 41

For partial seizures, What is the major difference between simple and complex partial seizure

Answer 41

In simple, consciousness INTACT with unilateral tonic-clonic movements In complex, consciousness IMPAIRED with 1-3 minute automatisms, postictal confusion, and hallucinations

Question 42

What is the course of the grand mal seizure

Answer 42

1.) Sudden loss of consciousness, with tonic phase (may lose breathing) then clonic phase for 30 seconds at least, then flaccid and comatose before regaining symptoms

Question 43

What are additional features of grand mal seizure

Answer 43

1. ) Postictal confusion and drowsiness for 10 to 30 minutes | 2. ) Tongue biting, vomiting, apnea, incontinence

Question 44

What is the course of absence seizure and how frequent is it

Answer 44

Child disengages from activity, stares into space, returns to activity seconds later and this episode only lasts for seconds Happens 100 times per day

Question 45

What is one similarity and difference between grand mal and petit mal seizure in terms of symptoms

Answer 45

Petit mal has impairment of consciousness similar to grand mal, but does not have loss of postural tone, continence, or postictal confusion

Question 46

What is the only test you usually need to do if someone has known epilepsy and comes presenting with seizure

Answer 46

Check anticonvulescent levels

Question 47

If this is the patient's first seizure with unknown epilepsy, what tests should be ordered

Answer 47

Most important: EEG (but not adequate alone for diagnosis) with neurology consult Other lab tests: CBC, electrolyte, blood glucose, LFT's, renal function tests, serum calcium, urinalysis Radiology tests: CT scan of head, MRI (important), LP and blood cultures if patient is febrile

Question 48

What is the first thing you must do if you see a patient in a seizure

Answer 48

ABC: Secure airway and roll patient to side to prevent aspiration

Question 49

In what percent of patients is monotherapy the only thing required for seizures

Answer 49

70%

Question 50

What is the medication strategy for seizures

Answer 50

Increase first convulascent until signs of tocxity appear, then add second drug. If patient symptom free for two years after, then begin to taper but confirm decision with EEG

Question 51

How do you determine risk of recurrence of seizures

Answer 51

With EEG - normal = much less recurrence

Question 52

When should you treat patient with seizures

Answer 52

Do not treat after first seizure, must also have abnormal EEG or brain MRI normal or patient is in status elepticus

Question 53

What is the treatment of grand mal and partial seizures?

Answer 53

Phenytoin and carbamazepine

Question 54

What is the treatment for petit mal seizures

Answer 54

Ethosuximide and valproic acid