Disorders of equilibrium Flashcards
1
Q
Vertigo
A
- illusion of movement of the body or environment, sensation,
- a hx finding
- “world spinning around me”, rotating or moving of the room / world
- classified as peripheral or central
- peripheral indicates inner ear or CN VIII problem
- central problem from brainstem, cerebellum (not usually as extreme)
2
Q
Ataxia
A
- incoordination or clumsiness of movement, motor problem, not weakness
- physical finding, may result from vertigo or other causes
3
Q
Syncope
A
- sensation of light-headedness
- faintness or giddiness w/o illusion of movement
- decreased supply of blood, O2, or glucose to brain
- typically vague presentation
- at extreme, lose consciousness & called snycope
- AKA falling out or fainting
4
Q
Cardiac dizziness / syncope
A
- rhythm disturbances or BP disturbances or mechanical problems (aortic stenosis, hypertorphic obstructive cardiomyopathy)
- may have hx of some cardiac abnormality (heart disease, abnormal ECG, echocardiogram, or stress test)
5
Q
Neurologic dizziness / syncope
A
- when stand up blood pools in legs, supposed to get reflex increase in heart rate and vasoconstriction so more blood goes to head
- w/ neurolgoic syncope instead get excess vagal stimulation, bradycarida and vasodilation - no blood to head = faint
- subtypes: orthostatic hypotension, vasomotor syncope, postmicturition syncope
6
Q
Orthostatic hypotension
A
- BP drops too much and can’t increase heart rate fast enough
- more in elderly, DM, on diuretics, alpha adrenergic blockers, anticholingerics
7
Q
Vasomotor / Vasovagal Syncope
A
- by far the most common type of syncope
- sudden increase vagal tone causes syncope by BP drop (stressful or painful situations)
- if a classic hx and attributable to situation minimal workup needed
8
Q
Postmicturition syncope
A
- Classicall increased vagal tone from urination causes syncope
- defecation/constipation: increased intraabdominal pressure - carotid body stimulation
- if you do Valsalva maneuver you get increased pressure on chest which increases pressure on carotid body - kicked in vagal response
9
Q
Syncope clinical signs and sx
A
- abrupt onset LOC, lasting for seconds to a few minutes and full recovery
- no post-ictal-like states (as in seizures)
- usually only very mild sx of disorientation (“how did I get on the floor?”)
- no confusion/fatigue
10
Q
Syncope PE
A
- do orthostatic BP
- cardiac and vascular exams looking for disease
11
Q
Syncope diagnostic tests
A
- not really needed for easily explained vasovagal syncope, unless recurrent and frequent
- ECG: look for arrhythmias, prolonged QT, signs of infarction or hypertrophy
- autonomic testing: tilt table testing looks for orthostatic hypotension
- electrophysiologic studies: as last resort - invasive studies of electricity of the heart
12
Q
Syncope tx
A
- tx underlying disease
- check state for driving recommendations for unexplained syncope
- if it doesn’t fit a reassuring pattern, consider workup for dangerous causes
13
Q
Stable stance
A
-need intact cerebellum, vestibular system, and sensation (vision and proprioception)
14
Q
Classifications of ataxia
A
- vestibular
- cerebellar
- sensory (propioceptive - vision problems)
- need to figure out which kind as it directs tx
15
Q
Vestibular ataxia
A
- same lesions that cause peripheral vertigo
- have abnormal stance or gait
- feel unsteady, but don’t fall down
- Romberg: stands okay with eyes open, not as good when closed (positive: when they wobble so much they need to take a step or fall down)
- can get mild vestibular ataxia with middle ear effusion or infection
16
Q
Cerebellar ataxia
A
- lesions of cerebellum or its connections
- see GREATEST ABNORMAL MOVEMENTS here w/ irregular rate, rhythm, amplitude or force of voluntary movements
- hard time standing with eyes open or close
- positive Romberg
- bad ataxia
- lack control of voluntary movement
17
Q
Sensory ataxia
A
- if lose proprioception become ataxic
- deficits most often in bilat peripheral nerves or posterior columns of spinal cord
- stand ok with eyes open, close eyes and fall
- decreased joint position sense and vibratory sense are diminished
- use a turning fork to test position sense though vibrations (big tuning fork)
18
Q
Other abnormalities in cerebellar disease
A
- hypotonia: poor posture, limbs easily moved by small force
- incoordination: acceleration and deceleration of movement decreased, jerky appearance, see best in walking
- eye movements: nystagmus, gaze paralysis or decreased pursuit movements
19
Q
BPPV
A
- benign paroxysmal positional vertigo
- problems with otoliths in semicircular canals
- always associated with nystagmus (horizontal only)
- benign, common, but scary
- antiemetics, ototlith repositioning, habituation
20
Q
Labyrinthine problems
A
- Meniere disease: triad (vertigo, hearing loss, tinnitus) and “drop attacks” - unable to stand (ataxic)
- vestibular neuronitis - mostly just vertigo
- labyrinthitis: multiple infectious causes with vertigo and hearing loss
21
Q
Central vertigo
A
- often heralds more serious neurologic problem
- usually from lesions that affect the brainstem vestibular nuclei or their connections
- central vertigo may occur with or without nystagmus
- if nystagmus is present it can be vertical, unidirectional, or multidirectional and may different in character in the two eyes
22
Q
Peripheral vs. Central vertigo
A
- Peripheral: intermittent vertigo (severe), nystagmus always present, hearing loss often present, brainstem/ cerebellar signs absent
- central: constant vertigo (less severe), nystagmus may be absent, hearing loss rarely present, brainstem/cerebellar signs present
23
Q
Weak, dizzy, lightheaded (WDL) hx
A
- how did it occur (sudden onset cerebellar (ataxia) suggest stroke)
- when did it occur? (changes in head or body position)
- describe sensation (does room spin, do you feel unsteady when walking, etc)
24
Q
weak, dizzy, lightheaded PE
A
- vital signs and orthostatics
- general: signs of other illness
- HEENT: inner ear or hearing loss, Dix-Hallpike, nystagmus
- CVD
- complete neuor exam (abnormality suggest cerebellar origin)
25
Q
Motor
A
Gait: any ataxia, wide base and unsteady
- cerebellar: look drunk, wide based, and staggering, tandem walking always impaired
- sensory: lift feet high off ground and slap down heavily (steppage gait)
- coordiante: leg ataxia or arm ataxia
- leg ataxia: run heel up and down other leg
- arm ataxia; irregular force, rate, rhythm, amplitude of rapid successive tapping
