Dizziness Flashcards
What is dizziness?
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What is giddiness?
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What does a complaint of dizziness cause tell medical providers?
Nothing, the complaint of “dizziness” is often viewed as a source of frustration for medical providers as it encompasses many potential disease states.
What are common disorders that are usually lumped together with dizziness?
Vertigo, presyncope/lightheadedness and disequilibrium.
What are other terms the patient might use to describe dizziness?
Lightheaded Faint Swimmy headed Foggy headed Swooning Off balance Woozy
What are the main causes of dizziness?
vertigo
presyncope
disequilibrium
What is the definition of vertigo?
The sensation of moving or spinning
What is the definition of presyncope?
The sensation associated with near fainting.
Lightheaded
Feeling foggy
Feeling “faint”
What is the definition of disequilibrium?
The sense of imbalance, usually while walking
How do we chose the best category for a complaint of dizziness?
Take a good history
What aspects of history taking allow us to differentiate the cause of dizziness?
Asking open ended questions
Allowing the patient to describe their “dizzy” sensation to you with out any prompting
Avoid leading the patient with words like spinning or lightheaded
Extrapolate associated symptoms
What do we have to keep in mind when allowing them to describe their dizziness?
give them time
What other factors do we need to get from them about their dizziness?
Precipitating factors
Associated symptoms
What are possible precipitating factors of dizziness?
Does it only occur upon rising from seated position, only while walking, only when turning the head
What are possible associated symptoms with dizziness?
Nausea, vomiting, hearing loss, tinnitus, chest pain, palpitations, dyspnea, headache, parasthesias, ataxia
What is pertinent to find out in the past medical history?
DM, Seizures, Migraines, Arrhythmia, MS, TIA/CVA, CAD, Anemia
antidepressants
Social Hx
Family Hx
What medications could cause these symptoms?
Digoxin, BB, some antibiotics, diuretics,
What in their social history can effect dizziness?
EtOH, drugs
What is pertinent to find out in the family history?
Arrhythmia, CAD, CVA, Migraine, DM, etc.
What do we need to include with the vitals?
orthostatics
What do we focus on with the PE?
HEENT Neck Pulmonary Cardiac Neuro
What do we look for with HEENT?
Focus on the ears, could be OM
What do we look for in the neck when assessing dizziness?
Carotid bruits, elevated JVP
What do we look for in pulmonary when assessing for dizziness?
Wheezes, basilar rales, tachypnea
What do we look for in cardiac when assessing for dizziness?
Irregular rhythm, murmur
What do we look for in neuro when assessing for dizziness?
Cerebellar findings, upper motor neuron signs, decreased sensation
What additional tests do we need to do in the PE when assessing for dizziness?
Hearing test
Visual acuity
Dix Hallpike maneuver
What labs do we run when we suspect dizziness?
CBC, BMP, d-dimer, cardiac enzymes, tox screen
When would you do an MRI when a patient comes in with dizziness?
If neoplasm or CVA suspected. Also may order an MRA if considering vascular phenomenon
When would you run an EKG on a patient that comes in with dizziness?
Suspect Arrhythmia or MI
When would we do an Electronstagmography
Evaluation of vestibular dysfunction if H&P aren’t enough
Frenzel googles
/-O-O-\
What is the most common cause of dizziness?
vertigo
What is vertigo an indication of?
A symptom of vestibular disease (Central vs. peripheral)
What are the symptoms of vertigo?
Patients experience a false sense of movement that may be described as spinning, whirling, tilting or moving
What are examples of peripheral vestibular disease?
Benign positional vertigo Ménière’s disease Vestibular neuritis Medications (ototoxic) Acoustic neuroma
What are examples of central vestibular disease?
Multiple sclerosis
Vertebrobasilar insufficiency
Migraine associated vertigo
What type of vertigo can be associated with deafness or tinnitus?
peripheral
What is benign postural vertigo?
Often idiopathic but may follow head trauma
and is most commonly attributed to calcium debris within the posterior semicircular canal
What are the symptoms of benign postural vertigo?
Symptoms occur with specific movements of the head and last one minute or less
Symptoms recur periodically for weeks to months without therapy
No other neurologic complaints
What is the treatment for benign postural vertigo?
Treatment is aimed at particle repositioning (Epley and Semont maneuvers)
What is Menieres Disease?
Age at onset usually between 20-40
Associated with endolymphatic hydrops with distortion and distention of the membranous, endolymph containing portions of the labyrinthe system.
May or may not be associated with underlying otologic disease
What are the symptoms of Menieres Disease?
Symptoms – episodic vertigo, senorineural hearing loss, tinnitus
What is the treatment of Menieres Disease?
Treatment aimed at reducing symptoms – treat vertigo, reduce or eliminating hearing loss
What is a definitive diagnosis of Menieres Disease?
“Definite” diagnosis of Meniere’s disease is Two spontaneous episodes of vertigo lasting at least 20 minutes
Audiometric confirmation of sensorineural hearing loss
Tinnitus and/or perception of aural fullness
What is the Vestibular Neuritits?
Generally considered to be a viral or postviral inflammatory disorder affecting the vestibular portion of the 8th cranial nerve
What are the symptoms of vestibular neuritis?
Characterized by rapid onset of severe vertigo with nausea, vomiting and gait instability. Severe symptoms usually last 2 days -2 weeks with residual dizziness/imbalance going on for several months
What is the treatment of vestibular neuritis?
Treatment with corticosteroids has shown some promise in the acute phase.
What is an acoustic neuroma?
Schwann cell derived tumors that commonly arise from the vestibular portion of the 8th cranial nerve. Account for ~8% of intracranial tumors in adults.
When do acoustic neuromas generally develop?
Median age at diagnosis is 50 y/o
What are risk factors for acoustic neuromas?
Risk factors include exposure to loud noise, neurofibromatosis, childhood exposure to low dose radiation
What are the symptoms of an acoustic neuroma?
Asymmetric hearing loss, tinnitus, unsteady gate, vertigo, facial parasthesia and pain
How do we diagnose an acoustic neuroma?
Diagnosis is made with MRI
How do we treat an acoustic neuroma?
Treatment options include surgery, radiation and/or observation
What are examples of ototoxic meds?
Various chemotherapeutic agents Erythromycin Gentamicin Neomycin Streptomycin Tobramycin Vancomycin – potentiates ototoxicity of Gentamicin
What med do we have to pay particular attention to for ototoxicity?
Genamicin
What is MS?
Multiple sclerosis, Autoimmune inflammatory demyelinating disease of the CNS
Who typically develops MS?
Primarily seen in women of child bearing age
What are the symptoms of MS?
Common symptoms – sensory disturbances in the limbs, visual changes, vertigo, balance problems
What is the treatment of MS?
Treatment – IV steroids, methotrexate
How do we diagnose MS?
Diagnosis – Clinical, MRI and/or LP
What is Vertebrobasilar Insufficiency?
Posterior circulation problem usually due to atherosclerosis
Additional symptoms of poor perfusion in the posterior circulation include: ataxia, dysmetria
In what patients should we consider Vertebrobasilar Insufficiency?
Should be considered in anyone with stroke risk factors
What is migranous vertigo?
Term used to describe episodic vertigo in patients with a history of migraine or other clinical features of migraine.
Patients with migrainous vertigo typically have no other neurologic symptoms and may not even have headache with the vertigo
What is migranous vertigo a diagnosis of?
exclusion
How do we treat migranous vertigo?
Treat with abortive therapy or prophylaxis
What is presyncobe/lightheadedness associated with?
Possibly a symptom of cardiovascular problems (or any other potential etiology of syncope)
May be a psychiatric phenomenon
What can cause presyncobe/lightheadedness?
Medications Cardiac arrhythmia Structural cardiac disease Hypotension Hypoglycemia or other metabolic disturbance Vasovagal presyncope Carotid sinus hypersensitivity Anxiety Depression
When is disequilibrium often seen?
Often a problem of the elderly but may present in younger patients with a history of head trauma, may also follow episodes of vertigo
What can disequilibrium be a sign of?
May represent CNS diseases such as Parkinsons
May be a visual problem
What can cause disequilibrium?
Parkinsons Visual disturbance Disorders of the cerebellum Polyneuropathy Multiple sclerosis
What are the specific symptoms associated with vertigo?
Spinning Head movements may exacerbate problem May only last a few minutes Associated nausea and/or vomiting Nystagmus
What are the specific symptoms of presyncope?
Lightheaded or feeling faint
May be exacerbated by rising from a seated or supine position
May have associated palpitations, nausea, diaphoresis, parasthesia
Anxiety reaction
What are the specific symptoms of disequilibrium?
Feeling off balance
May hold onto furniture while walking about the house
May be ataxic
Cerebellar signs on physical exam
What are other considerations for assessing dizziness?
CVA/TIA MI Intracranial bleed Carotid artery disease Lung disease/low O2
A 42 y/o man experienced the sudden onset of vertigo, nausea, vomiting and ataxia 3 weeks ago. The vertigo, nausea and vomiting resolved within 48 hours but the patient still had “dizziness”. He says “I walk like a drunk”.
evaluate
A 28 y/o woman complains of a 2 week history of dizziness. She denies hearing loss or tinnitus but does report a 2 week history of “numbness” below her waist that occurred about 3 months ago. PE reveals horizontal nystagmus with lateral gaze as well as vertical nystagmus on upward gaze. She has bilateral positive Babinski sign.
evaluate
A 69 y/o man complains of frequent “dizzy spells” over the last 6 weeks. He says that the episodes last ~30-60 seconds and he feels like he is going to pass out. They have occurred in many different situations including watching TV and while eating at a restaurant.
evaluate
A 39 y/o man had an episode of severe dizziness while at work. It caused him to collapse and vomit. With assistance, he got up and was noted to have an unsteady gait. His dizziness persisted. He has no significant PMH.
evaluate
