Approach to Giddiness Flashcards
What are the differentials for vertigo (vestibular)?
Central - Cerebellar infarct/ haemorrhage - Vertebrobasilar TIA - Tumour - Multiple sclerosis - Temporal epilepsy
Peripheral (hearing loss)
- Meniere’s
- Labyrinthitis
Peripheral (no hearing loss)
- BPPV
- Vestibular neuronitis
What are the differentials for faintness (pre- syncope)?
Cardiac (arrhythmia)
- Tacchyarrythmias: supraventricular (AF/AVRT/AVNRT) or ventricular (VT)
- Bradyarrythmias: sinus bradycardia, heart block, sinus arrest
- Stokes-Adams attack: syncope due to transient asystole
Cardiac (structural)
- Left ventricular outflow tract obstruction – aortic stenosis, HCM
- Right ventricular outflow tract obstruction – pulmonary stenosis
Peripheral Vascular Resistance
- Vasovagal (3Ps: Postural/prolonged standing, Provoking factors, Prodromal)
- Drugs (anti-hypertensives)
- Autonomic Failure (Parkinson’s Disease, DM, B12 deficiency)
- Reduced vascular tone (septicaemia, adrenal failure/hypocortisolism)
Blood
- Anemia
- Hypoglycemia
- Fluid Loss: diuretics, dehydration, haemorrhage, sepsis
- Vascular Access Steal syndrome / Dialysis-associated steal syndrome (rare)
Venous Return
- Pulmonary hypertension
- Pulmonary emboli
- Orthostatic hypotension
- Situational (cough, micturition)
What are the differentials for giddiness that is non- vertiginous and non- faint
- Floatiness/Heaviness
(Psychosomatic) - Unsteadiness (ataxia)
- Blankness (epileptic)
Clinical features of structural cardiac conditions?
- ___________ on exertion
- a/w ____________
- Family history of __________
- PMHx: _______________________
- O/E: murmur
Syncope;
SOB, chest pain;
sudden death;
AMI, cardiomyopathy, valvular heart disease, congenital heart disease
Clinical features of arrhythmias?
- Sudden onset __________ followed by syncope
- Syncope during _____________
- Previous MI or cardiac disease
- Drug history – recent cessation of __________________
palpitation
exertion or while supine;
beta-blockers, CCB
Clinical features of vasovagal syncope?
- Precipitating trigger: _________, _________, __________, _________, _________
- __________: external pressure to neck or head turning a/w nausea
pain, intense emotion, venopuncture, prolonged standing;
Carotid sinus hypersensitivity
Clinical features of postural hypotension?
- Definition: ______________
- Light-headedness shortly after standing
- Drug history – _________________
- PMH – _____________
BP drop >20mmHg systolic or >10mmHg diastolic;
antihypertensives, diuretics;
DM, Parkinson’s
Clinical features of anemia?
- Symptoms: _________, _________, ________, ___________
- GI bleed symptoms
- Diet hx, drug hx – anticoagulation, antiplatelet therapy?
- O/E: conjunctival pallor
chest pain, palpitations, pallor, dyspnoea
Clinical features of hypoglycemia?
Symptoms: nausea, sweating, tremors
DM patient on insulin
What is the work up for cardiac causes of dizziness?
- FBC (anemia, raised TW for infection)
- Blood glucose
- ECG (for arrythmias), consider Holter if hx suggestive
- Cardiac Echo if hx suggestive
What are the labyrinth causes of vertigo?
- BPPV
- Meniere’s Disease
- Labyrinthitis
What are the 8th nerve causes of vertigo?
- Vestibular neuronitis
* Acoustic Neuroma
What are the brainstem causes of vertigo?
- Vertebrobasilar TIA
- Intracranial lesion
- Multiple sclerosis
- Wernicke’s encephalopathy
What are the cerebellar causes of vertigo?
Cerebellar infarct or haemorrhage
What are the temporal lobe causes of vertigo?
- Epilepsy
* Vertiginous Migraine
What are the CNS symptoms and signs seen in patients with central vertigo?
CN signs/symptoms
- Ptosis
- Diplopia
- Facial numbness, weakness
- Dysphagia
- Dysarthria
Long tract signs (paraesthesia, weakness)
Cerebellar ataxia
Visual loss (hemianopia)
Signs of raised ICP
Headache
What is peripheral vertigo associated with?
- may be associated with deafness, tinnitus or fullness of ear
- nausea and vomiting are usually severe (less reliable)
- Recent URTI, trauma
What is the nature of central nystagmus?
- Changes direction with gaze: fast component to direction of gaze (gaze-evoked nystagmus)
- Rotatory (pure rotatory, not mixed)
- Vertical
- Non-fatigable
What are the clinical features of BPPV?
- Vertigo only with postural change, intermittent, recurrent
- No tinnitus/deafness.
- Lasts seconds to minutes
What are the clinical features of Meniere’s disease?
- Recurrent spontaneous vertigo.
- Lasts half an hour to several hours
- a/w tinnitus, deafness, ear fullness
What are the clinical features of Labyrinthitis?
- Spontaneous acute vertigo; persistent (days)
- Nausea/vomiting
- Hearing loss
- +/- otalgia/ otorrhea
- +/- fever
What are the clinical features of vestibular neuronitis?
- Spontaneous acute vertigo; persistent (days)
- Nausea/vomiting
- No tinnitus/deafness
- Positive Unterberger test: Patient asked to march in place, rotation towards one side indicative of ipsilateral labyrinthine lesion but is not diagnostic
What are the clinical features of vertibrobasilar TIA?
CN signs/symptoms
- Ptosis
- Diplopia
- Facial numbness, weakness
- Dysphagia
- Dysarthria
Long tract signs (paraesthesia, weakness)
Cerebellar ataxia
Visual loss (hemianopia)
HiNTs – Jerky pursuit, skew deviation, central nystagmus, negative VOR
What are the clinical features of intracranial lesion?
- Focal neurological deficit
- Signs of raised ICP
- New onset headache
- Progressive hearing loss
What are the clinical features of vertiginous migraine?
Five or more episodes of headache with:
- severe and unilateral orbital, periorbital or temporal pain
- duration 15-180 min, frequency 1 per 2 days to 8 per day
- > 1 restlessness/agitation or ipsilateral facial signs
What are ototoxic drugs?
Gentamicin, Vancomycin, Cisplatin, Frusemide, etc
