L6 - CLINICAL APPROACH TO DIZZINESS + VERTIGO

Question 1

What is the most important aspect of diagnosing the etiology of dizziness in a PT?
(emphasized)

What is the purpose of the physical exam in diagnosis?

Answer 1

Patient’s description of dizziness (HPI/Hx)

PE is used to CONFIRM the DX (it does NOT make the DX)

Question 2

40% of dizzy patients have ___ dysfunction

MCC of dizziness

Answer 2

40% of dizzy patients have ___ dysfunction

peripheral vestibular
(inner ear) (peripheral bc
outside of brain)

Question 3

What are 2 types of positional vertigo?

Which of these types is the MCC of positional vertigo?

Answer 3

1. Benign positional vertigo:
   MCC
   c/b Canalith (Ca2+ stones dislodging)
2. Vestibular neuritis:
   inflammation of vestibular system by meds/INFXs

Question 4

10% of dizzy patients have a central ___ lesion

Answer 4

central brainstem lesion

or cerebellar

Question 5

How would you differentiate b/w a central and peripheral cause of dizziness?

(emphasized)

Answer 5

Neurological exam

If dizziness has central etiology = abnormal neuro exam

If dizziness has peripheral etiology = normal neuro exam

Question 6

Vertigo is caused by displacement of ___ from the ___

Answer 6

Vertigo is caused by displacement of otoconia from the utricle

Question 7

Vertigo is defined as

Answer 7

Vertigo is defined as an illusion of motion - spinning sensation / sense of swaying or tilting

(some PTs may interpret this
as self-motion others as motion of the environment)

Question 8

What kind of medications c/c vertigo?

Answer 8

Antibiotics

aminoglycoside toxicity

Question 9

Clinical features of central vs. peripheral vertigo

• neuro signs?
• deafness or tinnitus?

Answer 9

Neuro signs:

• periph = absent
• central = often present

Deafness or tinnitus:

• periph = m/b present
• central = absent

Question 10

The Dix-Hallpike maneuver is done to look for __

Answer 10

The Dix-Hallpike maneuver is done to look for rotational nystagmus

must be done on R/L side
head must be behind table
eyes must be open

Question 11

If rotational nystagmus is seen on the right side (but not on the left) when performing the Dix-Hallpike maneuver, what would you name this dysfunction?

Answer 11

Right benign positional vertigo

Question 12

If rotational nystagmus is seen when PT is moved either up or down when performing the Dix-Hallpike maneuver, what is this suggestive of?

Answer 12

Peripheral vertigo

Question 13

Epley’s Maneuver is used to treat ___

Answer 13

Unilateral benign positional vertigo (displaced crystal)

-only TX’s one side

Question 14

Pre-syncope is defined as __

What are the MCC’s?

Answer 14

Presyncope is the prodromal SX of fainting/near faint
“nearly blacking out or fainting”
lightheadedness, feeling of warmth, diaphoresis, nausea, visual blurring occasionally proceeding to blindness

HX of cardiac dz is relevant

MCC’s include orthostatic HTN, cardiac arrhythmias and vasovagal attacks

Question 15

A. How do you measure/DX orthostatic HTN?

B. What findings would you expect to see?

Answer 15

A. Have PT sit down and measure baseline BP + HR, then instruct PT to stand up

B. Orthostatic HTN is DX’d if the following is seen within 3 minutes of standing:

1. SBP decrease of @ least 
   20 mmHg
...or...
2. DBP decrease of @ least 
    10 mmHg
...and/or...
3. HR increase of > 20 BPM

*(20/10/20)

Question 16

A. Disequilibrium is defined as a sense of imbalance that occurs primarily when __

B. What is the MCC of disequilibrium? What does it lead to?

Answer 16

A. walking

B. peripheral neuropathy (l/t proprioceptive impairement)

Question 17

Peripheral neuropathy which leads to proprioceptive impairment c/b caused by

Answer 17

• DM
• B12 deficiency
• Spinal dz (myelopathy)

Question 18

Patients with dizziness caused by disequilibrium/imbalance tend to walk with a ___ gait + have a positive ____ sign

Answer 18

• wide based gait
• positive Romberg’s sign

required observation of gait + neuro exam to ID disequilibrium/imbalance dx
(emphasized)

Question 19

What are MCC’s of non-specific dizziness?

Answer 19

1/4 of PTs have major depression (bold)

1/4 of PTs have generalized anxiety or panic disorder (bold)

The remainder have somatization disorder, alcohol dependence and/or personality disorder (bold)

Non-specific dizziness can also be 2ndry to medications (HTN, DM, SSRI’s/SNRI’s)

Hyperventilation