dizziness Flashcards
assessment
Hx and PE = key. labs/imaging = not very helpful
“dizziness”
is subjective and can mean many things and must be clarified
5 categories of “dizziness”
vertigo, pre-syncope/syncope, dysequiligrium, ill-defined lightheadedness, true muscular weakness
vertigo
perception of rotation or spinning sensation. feels like “drunk” or “sea-sick.” is it peripheral or central? associated w/hearing loss or tinnitus?
central vs. peripheral vertigo: onset
central: slow. peripheral: rapid
central vs. peripheral vertigo: severity
central: mild. peripheral: worse
central vs. peripheral vertigo: CN findings
central: +, peripheral: -
central vs. peripheral vertigo: latency
central: -, peripheral: +
central vs. peripheral vertigo: nylen-barany
central: nystagmus persists. peripheral: nystagmus extinguishes
central vs. peripheral vertigo: etiologies
central: brain stem ischemia, posterior fossa tumors, MS, drugs: anticonvulsants, PCP, ethanol. peripheral: acoustic schwannoma, meniere’s dz, labyrinthitis (infection), BPV, trauma (endolymphatic fistula), labyrinthine concussion
peripheral vertigo
recurs and abates every few hrs. more violent and severe = more likely peripheral
central vertigo
gradual onset, contant, not affected by movement. brain stem or cerebellar Sx including dysphasia, dysphonia, ataxia, diplopia, miosis, or b/l blurred vision = common. may be acute onset if acute ischemia is cause but will see cranial nerve findings
vertigo w/+ hearing loss
acute labyrinthitis, typically URIs/otitis media
vertigo w/+ hearing loss and tinnitus
= classic triad of meniere’s dz. often occurs in middle age, can recur and Sx increase w/each recurrence until peaks and slow decrease in intensity. hearing loss typically persists between episodes
trauma-related vertigo
perilymphatic fistula -> leakage of endolymph from round or oval window into middle ear. pts complain of acute worsening of dizziness when middle ear pressure increases during coughing, sneezing, or straining. nonspecific dizziness may be seen as part of post-concussive syndrome but the increase in Sx w/coughing is not seen. labyrinthine concussion or post-traumatic positional vertigo
vertigo: PE
good neuro exam = key, particularly CNs, cerebellar fxn, nystagmus, and positional testing. nystagmus seen in central and peripheral. best observed in the dark so pt has nothing to fixate on (can extinguish peripheral nystagmus)
peripheral nystagmus
rotatory or horizontal
central nystagmus
vertical or dysconjugate
nylan-barany maneuver
aka dix-hallpike. fast phase toward effected ear
presyncope/syncope
due to dec. cerebral blood flow. caused by anything that alters body’s normal vascular reflexes. typically “dizziness” only happens when pts. stand. assess for volume loss.
dysequilibrium
= unsteady, stumbling gait disturbance. cause = loss of significant sensory fxn: sight, light touch, proprioception. dizziness often goes away w/holding onto stationary object.
dysequilibrium: PE
visual acuity, fudoscopic exam, complete neuro exam w/focus on light touch, pinprick, proprioception in lower ext. pts. may have wide based or stumbling gait but not ataxic - can test cerebellar fxn w/finger nose + rapid alternating movements. must be careful to do good neuro exam to evaluate for true weakness or ataxia.
dysequilibrium: etiologies
poor vision, diabetic or ethanol neuropathy, B12 deficiency, tabes dorsalis. can also be a Sx of motor gait disturbances due to cerebellar degenteration or PD - neuro exam helps differentiate
ill-defined lightheadedness
very vague. often suggests psych etiology e.g. depression, hyperventilation, anxiety, meds. if pt appears ill or many med problems, may be hyperCa, hyperMg, uremia, anemia, chronic subdural hematoma, myocardial ischemia
