Dizziness And Vertigo Flashcards
Sequence of events and symptom analysis
Tell me more
Specificity- what do you mean by dizziness
Timeline- the first time it happened, what were you doing? How long did it last. Have the attacks been the same since. Is it there all the time or does it come and go. Does it come on slowly or suddenly
Triggers- does anything bring it on ie. Turning head in one direction or another. Lying down in bed? Standing up? Sitting down? Anything make it better or worsen
Systems review
Hearing- any changes Ears- earache, discharge, ringing Sensory- numbness or tingling anywhere, changes in vision or eye pain Motor- feelings or weakness, difficulty with daily activities, balance Speech- trouble recently Headaches Falls and blackouts Constitutional- FWARJCNL
Patients perspective
Feelings and effect on life
Ideas
Concerns
Expectations
Background
PMH- strokes, infections, trauma
DH- any recent changes
FH
SH- are you under the influence when the dizziness comes on
Central vs peripheral vertigo
Central (CNS)
Peripheral (inner ear)
Central lasts longer, is more intense and is associated with other neurological symptoms
Peripheral tends to get better with time, central causes tend not to
BPPV
Only lasts for seconds and is precipitated by looking up and to one side (classically when lying down in bed)
No deafness or tinnitus
Usually asymptotic between attacks
Labyrinthitis
Sudden onset
Acute attacks lasts for days- typically 3 days of an acute attacks, 3 weeks of being unsteady, and 3 months before back to normal
Severe difficulty staying on their feet, as well as nausea and vomiting
Acute labyrinthitis- deafness
Vestibular neuronitis- no deafness
Ménière’s disease
Triad of vertigo, tinnitus, progressive hearing loss (usually unilateral)
Warning- fullness in the ear before the attack
Attacks typically last a few hours
Drop attacks
Labyrinthitis- one continuous attack, Meniere’s- episodic
Ototoxicity
Streptomycin, vancomycin, gentamicin, chloroquine’s, chemotherapy are all potentially ototoxic
Can cause deafness and tinnitus
Herpes zoster Oticus (Ramsay hunt syndrome)
Singles- reactivation of varicella zoster virus in the genticulate ganglion of the facial nerve
Extremely painful and blistered external meatus
Facial palsy, deafness, and tinnitus
Stroke/TIA
Other neurological symptoms present
Elderly with other risk factors for a stroke
Severe, persistent symptoms with severe imbalance
Vestibular migraine
Minutes to hours or even days
Mimics Ménière’s disease but NO HEARING LOSS
usually a PMH of classical migraine
Can’t tolerate being a passenger in a car
Eased by sleep and rest and brought on with stress
Other causes of central vertigo
MS
Head injury
Intracranial haemorrhage
Investigations for vertigo
Full otoneurological examination, including cranial nerves and gait
Eye examination for nystagmus
Otoscopy
Dix hall pike test for BPPV
Audiometry
MRI head if concern regarding central cause or neurology found
HINTS (head impulse)
General management of vertigo
Review medications and stop ototoxic drugs, consider risks of driving and occupational hazards
Treat vertigo and nausea acutely with anti emetics (PROCHLORPERAZINE is a good one as it has vestibular action- but be careful it can cause Parkinsonism so only use short term)
