dizziness

Question 1

which cause of vertigo would you expect to see as reoccurrent and brief (lasting seconds)

occurring with predictable head movements

Answer 1

BPPV

Question 2

Which type of vertigo cause would you expect to see in single episodes with acute onset lasting days

Answer 2

vestibular neuritis

Question 3

which cause of vertigo would you expect to see with reoccurring episodes lasting several minutes to hours

Answer 3

Meniere’s

Question 4

describe central nystagmus

Answer 4

vertical, pendular
fast beat towards lesion
not relieved by gaze fixation
cerebellar signs

Question 5

describe peripheral nystagmus

Answer 5

horizontal and jerking
fast beat away from lesion side
relieved by gaze fixation
no cerebellar signs

Question 6

what type of nystagmus would we see with BPPV
vestibular neuritis
and menieres disease

Answer 6

all peripheral

Question 7

which cause of vertigo would we expect to see with ear fullness or pain and hearing loss or tinnitus

Answer 7

Meniere’s

Question 8

Unilateral sensorineural hearing loss suggests a _____

Answer 8

Unilateral sensorineural hearing loss suggests a peripheral lesion;

Question 9

Ataxia/Fall indicate what cause of vertigo

Answer 9

cerebellar

Question 10

with syncope and dizziness what do we think

Answer 10

→ could be autonomic, vascular, think more about heart stuff

Question 11

head thrust test is usually abnormal with what cause of vertigo

Answer 11

vestibular neuritis

deficient vestibuloocular reflex (VOR) on the side of the head turn (off target), implying a peripheral vestibular lesion (inner ear or vestibular nerve) on that side

Question 12

associated with endolymphatic hydrops with distortion and distention of the membranous, endolymph-containing portions of the labyrinthine system

Answer 12

Meniere’s

Question 13

Main symptom of vestibular disease

Answer 13

vertigo

Question 14

“room spinning” or “rocky boat”

is a common descriptor of

Answer 14

VERTIGO

Question 15

Mainstay of treatment for BPPV i

Answer 15

particle repositioning maneuvers

Usually send pts home with instructions on how to do this on their own

Treatment includes pt edu, meclizine for symptom relief, return precautions

Question 16

when would you worried about vertigo

Answer 16

Hearing loss/tinnitus, brainstem sx, lasting longer than a few weeks

Refer to Neuro if CNS s/sx develop

Question 17

what referral should you make for a pt with BPPV

Answer 17

Refer to ENT if persistent peripheral vertigo

Question 18

differential diagnosis of syncope

Answer 18

seizure
TIA
anxiety
acute hemorrhage
DROOGS

Question 19

RF for syncope

Answer 19

Cardiovascular disease is the major risk factor
History of stroke or TIA
Low BMI = low BP = prone to syncopal episodes
much higher risk of vasogenic syncope
Increased EtOH intake
Diabetes or elevated blood glucose levels

Question 20

most common cause of syncope

Answer 20

vasovagal

Question 21

other than vasovagal what are some causes of syncope (5)

Answer 21

Orthostatic hypotension, carotid sinus hypersensitivity, situational

Cerebrovascular disease – < 1%

Cardiovascular disease – 23%

Arrhythmias, conduction abnormalities, blood flow obstruction

Question 22

how frequently do you see seizures as the cause of apparent episodes

Answer 22

Seizure is cause in 5-15% of apparent syncopal episodes

Question 23

how to differentiate seizure from syncope

Answer 23

postictal state, confusion, slow recovery, incontinence,

injuries especially tongue biting, tonic-clonic movements

Question 24

PE for syncope

Answer 24

Orthostatic blood pressure
isturbances in heart rhythm or breathing
Cardiac auscultatory findings
Physiologic maneuvers (Valsalva)
Abnormal neurologic findings
GI bleeding (stool guaiac)
Carotid sinus massage (check for bruits first!))

Question 25

diagnostic tests for syncope

Answer 25

EKG
CHEM7: 
CBC
sugar check 
cardiac enzymes 
Toxic screen 

ECHO

Question 26

what is the prodrome seen with vasovagal syncope

Answer 26

50%

of diaphoresis, nausea, pallor, weak/fatigue, lightheaded
Initiated by offending stimuli

Question 27

triggers for vasovagal syncope

Answer 27

Hot environment, EtOH, fatigue, pain, hunger, prolonged standing, venipuncture, fear

Question 28

pathophys with vasovagal syncope

Answer 28

Stimuli → increased peripheral sympathetic activity, venous pooling → cardiac/vagal reflexes inhibit sympathetic fibers, increase parasympathetic activity → vasodilation, bradycardia → hypotension, syncope

Question 29

preventing vaovagal syncope

Answer 29

can prevent it by sitting down

and preventing triggers

Question 30

permanent pacemaker is helpful in what syncope

Answer 30

only really in cardiogenic

Question 31

why would you get a chem 7 in a pt with suspected seizures

Answer 31

looking at electrolytes and sugar

Question 32

why would you get a cbc in a pt who you suspected had a sezirue

Answer 32

to check for bleeding/ hemorrhage

Question 33

define orthostatic hypotension

3

Answer 33

Postural decrease in SBP ≥ 20mmHg

Decrease in DBP ≥ 10mmHg

Increase in HR ≥ 10 bpm

Symptoms reproduced on tilt testing

Question 34

30% of elderly pts experience syncope for this reason

Answer 34

30% of the elderly

orthostatic hypotension
loss of vasoconstrictive reflexes in LE vessels → fall in systolic BP → syncope

Question 35

major drug types that cause orthostatic hypotention

Answer 35

Antidepressants, antihypertensives, opiates

Question 36

tx for pt with orthostatic hypotension

Answer 36

Tensing the legs while standing; dorsiflexion of the feet before standing
allows for equalizing

Arising slowly in stages and hold onto something
Wearing compression stockings to minimize venous pooling
especially if pts spend a lot of time sitting

Various drug therapies

Question 37

when do we see carotid Sinus Hypersensitivity

Answer 37

men >50

pressure at the carotid leads to a pause of 3 seconds or more

Question 38

pathophysiology of situational syncope

Answer 38

Straining-type maneuver contributes to decreased BP by decreasing venous return
Increased ICP 2˚ to increased intrathoracic pressure which decreases cerebral blood flow

Question 39

Most common cardiac cause of syncope

Answer 39

arrhythmias

specifically
bradyarrhythmias

Question 40

causes of sinus bradycardia

Answer 40

Intrinsic sinus node disease (sick sinus syndrome), drugs (β-blockers), or autonomic imbalance

Question 41

what type of AV block would require a pacemaker

Answer 41

Type II second degree block is often progressive and warrants permanent pacemaker

Question 42

why do we see supraventricular tachycardia causing syncope and what would be the predrome

Answer 42

Most commonly due to underlying structural heart disease, particularly CAD

preceded by palpitations or lightheadedness; may be abrupt onset

Question 43

treatment for supraventricular tachycardia

Answer 43

Treatment includes antiarrhythmic drugs, ICD, radiofrequency ablation

Question 44

MC blood flow obstruction that lead to syncope are:

Answer 44

aortic stenosis, hypertrophic cardiomyopathy

Question 45

less common blood flow obstructions that lead to syncope are

Answer 45

Less common include pulmonic stenosis, PE, pulmonary HTN, atrial myxoma

Question 46

common EKG findings with aortic stenosis

Answer 46

LVH, LBBB common

Question 47

how would you diagnose aortic stenosis

Answer 47

echo

Question 48

aortic stenosis

Answer 48

Cardiac cath may be needed for pts with severe stenosis and/or presence of CAD
High mortality if untreated
Treatment is usually surgical correction by aortic valve replacement

Question 49

Up to 30% of patients who have dynamic outflow obstruction

in the familia cause of HTN

Answer 49

young person playing sports

Question 50

poorly predicted outcomes with syncope are associated with these 5 things

Answer 50

Hct < 30%
Abnormal EKG
Systolic BP < 90 mmHg
Complaint of shortness of breath
These patients presenting with syncope are more likely to have a serious cardiac outcome such as acute MI