NEURO- DIZZY SYNCOPE Flashcards
1
Q
What ROS questions are specific to Vertgo?
A
Is the room spinning, are you moving around room
2
Q
What are Ros question specific to synconpe?
A
loss of balance
loss of orientation in space
3
Q
What happens prior to fainting/syncope?
A
Presyncope- lightheadedness
+/- collapse
4
Q
What are causes of dizziness?
A
anxiety stress, pathology, substance use, motion, autonomic dysfunction, dehydration,
5
Q
What is the MC cause of dizzyness?
A
40% vestibular ○ 25% other ■ Presyncope ■ Disequilibrium ■ Hypoglycemia ■ Hyperventilation ■ Head trauma/whiplash
6
Q
What are concerns with elderly dizziness?
A
Many MC-Vertigo 20% Central brainstem vestibular dysfunction peripheral neuropathy, parkinsonism, cerebellar disease, cervical myelopathy. Depression Cardia dz
7
Q
What is the DDx for younger adults and dizzyness?
A
Psych Presyncope-dizziness only in the upright posture, pallor 50% somatization, 25% depression, 25% anxiety/panic, substance use, personality d/o; fibromyalgia,
8
Q
What is the key differential in vertigo?
A
illusion of movement, not spinning,
exacerbation by head movement.
nystagmus- eye movement rapid
9
Q
Ms. Jessica has tinnitus assoc with movement dizzyness? Which location is his vertigo?
A
PERIPHERAL- middle ear
ABSENT Neuro
Nystagmus:
Unidirection
Fast to normal ear
Fixation suppressed
10
Q
Ms. Cassidy has ataxia and vomiting assoc with her vertigo? What location is a concern?
A
CENTRAL- CNS \+: HA, double vision, visual loss, slurred speech, numbness of the face or body, weakness, clumsiness
Nystagmus
REverses any direction
Fixation Normal
Neuro present
NO auditory dysfx
11
Q
What is DDX if pt has Sweating + dizziness ?
A
sympathetics → Anxiety or Thyroid issue
W/u
TSH
Blood glucose
12
Q
What is DDX if pt Tinnitus or hearing loss +dizzy?
A
Meniere’s disease
13
Q
What is DDX if pt Ataxia + dizzy?
A
cerebellum
CT or MRI
associated dysarthria and eye signs, such as gaze-evoked nystagmus, poor smooth pursuit, and downbeat nystagmus. If the cerebellar hemisphere is also involved, there will be incoordination of limbs.
14
Q
What PE test are used for neuro DDX findings?
A
orthostatic changes
gait
nystagmus
15
Q
During Weber test, Mr. space has hearing towards affected ear? What may that indicate?
A
CONDUCTIVE LOSS
TX cereumen removal
16
Q
During Weber test, Mr. Air has hearing towards UNaffected ear? What may that indicate?
A
SENSIONEURAL LOSS
17
Q
During Rinne’s the Pt hears the air more than vibration on mastoid?
A
NORMAL
18
Q
During Rinne’s the Pt hears the vibration more than aire
A
Bone conduction greater than air=
CONDUCTIVE LOSS
19
Q
A 38 yo female c/o dizziness x 2 days. She rolled over to get out of bed and has been episodic
with head movement. She describes the room as spinning and reports nausea, no vomiting. She had a URI last week, denies sinus pressure or fever. ROS neg.
A
BPPV- PERIPHERAl
MC elderly
W/u: Dixpike +
TX- Particle repositioning maneuevers
meclizine (dramamine)
REFER-Neuro sx develop
ENT if persistent peripheral vertigo
20
Q
Why is dizzy with movement indicated vestibular problem?
A
endolymph in the inner ear moves with head movement and stimulate the hair cells → brain interprets how we are moving in space
21
Q
What cause of vertigo is indicated below Time: single episode, last days CP: URI Nystagmus: Peripheral, toward normal ear Neuro sx: side of lesin, no brainstem Auditory:NOne Findings: Head thrust Normal
A
labrynthitis (vestibular neuritis)
22
Q
What cause of vertigo is indicated below Time: single episode, last days CP: URI Nystagmus: Peripheral, toward normal ear Neuro sx: side of lesin, no brainstem Auditory:NOne Findings: Head thrust Normal
A
Meniere
23
Q
What cause of vertigo is indicated below Time: seconds CP: sx w/ headmovement Nystagmus: Peripheral, toward normal ear Neuro sx: NONE Auditory: NONE Findings: + DixHalpike
A
Bening Paroxysmal position vertigo
24
Q
What cause of vertigo is indicated below Time: recurrent, min-hrs CP: FHx. PMH, HA Nystagmus: Both Neuro sx: UL, n/v Auditory: NONE +/- Findings: Normal w/o sx
A
Migraine Vertigo
25
```
What cause of vertigo is indicated below
Time: single recurrent, min-hrs
CP: older, vascular risk, trauma
Nystagmus: Central
Neuro sx: brainstem sx
Auditory: NONE +/-
Findings: MRI lesion
```
TIA Vertebrebasillar
26
```
What cause of vertigo is indicated below
Time: sudden, day-wks
CP: older, vascular rsk, trauma
Nystagmus: Central
Neuro sx: brainstem, lateral medullary
Auditory: +/- w/ cerebellar aa
Findings: MRI lesion
```
Brainstem infraction
27
```
What cause of vertigo is indicated below
Time: sudden, d-wks
CP: older HTN
Nystagmus: Peripheral, toward normal ear
Neuro sx: gait, HA, dysphagia
Auditory: NONE
Findings: URGENT MRI/CT
```
Cerebellar infraction or hemorrhage
28
An 82 yo male with CAD s/p MI 2y. “nearly passing out” after breakfast. He was sitting in a chair, became diaphoretic & confused, which lasted a few mins then resolved; feels well now.
```
PE: orthostatic VS,
Check vision,
Complete neuro,
complete CV/carotid
/PV
```
DX-TIA d/t CAD and mental status
29
A 23 yo female near syncope. felt lightheaded, sweaty & “started to black out” a few hrs ago. Feeling passed. She feels well now, but anxious. No PMH, no meds, no drugs.
● VSS, no orthostasis, PE unremarkable
Ddx: dehydration, hypoglycemia
30
A 62 yo male c/o feeling unsteady on his feet for several weeks, occurs primarily when walking. Denies falls,
ataxia, dizziness, vertigo, assoc s/sx.
● PMH: Hyperlipidemia, OA (osteoarthritis)
```
Ddx: peripheral neuropathy-DM, vitamin B12 deficiency/EtOH
Parkinsonism,
cerebellar dz,
MSK d/o,
poor eyesight
```
PE: orthostatic VS, vision, gait, MSK, complete neuro
31
What may result from peripheral neuropathy, a musculoskeletal disorder interfering with gait,
vestibular disorder, a cerebellar disorder, and/or cervical spondylosis.
Parkinson -subject to postural hypotension, imbalance. Cervical spondylosis- associated with dizziness
Visual impairment
Disequilibrium
32
This treatment is for home
1. He sitting w/ head turn 45deg R, pillow to support head and shoulder. Start w/ affect ear
2. Lie back quickly
3. Hold 30s
4. Turn head L 90d
5. Hold 30s
6. Turn body to Left
Modified Epley Self tX
| Particle positioning- Sit upright fast in clinic
33
What is LOC due to reduced cerebral blood flow associated with the absence of postural tone (collapse) and spontaneous, rapid and complete recovery
```
Syncope
NO Post ictal state in syncope vs. seizure
Injury assoc- Head -toe exam, teeth**
Benign
Self limited- rapid recovery
```
34
What happens in GI that can lead to impaired consciousness?
```
Large acute GI bleed
Other
seiure
TIA
GAD
Hypoglycemia
Meds
```
35
What is concerning about syncope in elderly?
```
75% will experience
Sign of cardiac arrest-M
M+W
CV dz major risk
Stroker or TIA
Low BMI
Alcohol
DM
```
36
What happens in the brain during syncope
Reduction/underperfusion of cerebral blood flow
d/t dyfx of brain metabolism from low BP
Stimuli → increased peripheral sympathetic activity, venous pooling → cardiac/vagal reflexes inhibit
sympathetic fibers, increase parasympathetic activity → vasodilation, bradycardia → hypotension, syncope
○ It’s a mismatch between sympathetic and parasympathetic activities
37
What are the NONCARDIOGENIC Reflex CAUSES syncope?
Reflex-vasomotor- pons, baroreceptors carotid body
vasovagal/vasodepressor- Neurocardiogenic vasoconstriction
Over PNS, under SNS
Micturition- pee shiver
Deglutition-swallow
Cough
38
What are the NONCARDIOGENIC orthostatic hypotension CAUSES syncope?
dysautomias
fluid depletion
Illness, bedrest
SSRI, SNS blockers
39
What are cardiovascular disease related to syncope?
```
arrhythmia
AV block w/ bradycardia
Sinus sinus syndrome
V-tach d/t structural damage
Hypertrophic cardiomyopahty- BF obstruction DEC CO
Aortic Stenosis- BF obstuctin, DEC CO
```
40
What are MAJOR CV uncommon causes of syncope?
```
Supraventricular TACh
LONG QT
MI
R-ventricular dysplasi
Pulmonary embolus
Pulmonary HTN
Dissecting aortic aneurysm
Atrial myxoma
Cardiac tamponad
```
41
What are MAJOR uncommon causes of syncope?
```
Reflexes-
defecation,
glosspharygeeal,
postprandial
Carotid sinus hypersensitive
Hyperventialtion
Migraine
Carcinod syndrome
Hypolglycemia
Hypoxia
multivessel obstructive cerebrovascular
```
42
What type of syncope occurs with fear, pain, emotional, standing or prodromal sx?
Vasovagal
43
What type of syncope occurs after urination, defecation, cough, or swallowing?
Situational
44
Mr. Glass has acute ischemia w/ MI on ECG. What is type of syncope
Cardiac ischemia
45
Ms. Harper has sinus bradycardia <40. What type of syncope?
Arrhythmia
46
Person is supine for 5min. Then measure 1-3min of standing. Record lowest BP.
```
Orthostatic hypotension
DEC in SBP >20 or SBP 90
Postural decrease in SBP ≥ 20mmHg
○ Decrease in DBP ≥ 10mmHg
○ Increase in HR ≥ 10 bpm
Tilt testing INC sx
```
47
Ms. Harper 67 had an episode of syncope. What should be the EXAM?
```
Orhtostatic BP
CV auscultate
Valsalva maneuver
Neuro exam
Stool guaiac
Carotid massage- BRUITS 1ST
```
48
Due to Ms. Harper syncope episode what labs should be next?
```
Chem 7- electrolytes
CBC- H&H
Tox screen-drugs
UPT
EKG- arrhythmia, conduction
```
49
Mrs. Harper has h/o of murmurs? What diagnostic test for Ms. Harper?
Ambulatory monitoring
EEG
Exercise test
Upright tilt table testing- Neuro
50
If metabolic cause is suspected, what should be order
Chem 7
| CBC
51
If patient have heart disease or suspected what should be orderd?
1st
ECG
Echo
52
Ms. Harper c/c of chest pain and syncope, what is next step?
Echo
ECG monitoring
Stress test
53
Ms. Tina 13yo h/o syncope after standing. No suspicion of heart dz or neuro. What is next testing?
Tilt test
54
The person is 77yo has no h/o of CV dz or neuro deficits, and has sx of syncope w/ Neck turning? What is first evaluation?
Carotid massage
| Auscultate bruits 1st
55
Ms. Jasmine is 14 yo h/o syncope during track race? Waht is initial step
ECG
| Stress test
56
Mr. Jet was diaphorect, nause, pallor, weak, lighthead b4 his syncope episode. What is MC?
Neurocardiogenic Vasovagal
MC cause
Young healthy
Triggers- fear, standing, venipucture, pain, alcohole, hot
57
What are recommendations for Mr. Jet and syncope?
```
Remove stimuli
Hydration
Lie down, if feel sx
B-blocker
Pacers
```
58
What occurs in defect in postural vasomotor reflexes?
Vasoconstriction should occur with upright position- inc perfusion back to heart.
1. Loss of vasoconstriction upright
2. Fall in systolic BP- dec perfusion
3. DEC to brain
4. Syncope
59
Mr. Hooper is 77yo male h/o CHF many medications. What are his risk?
```
Orthostatic hypotension
Elderly- deconditioned
DM
Autonomic and peripheral neuropathy
Hypovolemia-
Blood loss
MEDS- diuretic, adrenergic(SNS) blocking agents
FH
```
60
how is orthostatic hypotension managed?
```
Compression stocking
Avoid volume depletion
REview meds
Don't tense leg while sanding
Slow movement to upright
```
61
What is condition when pressure/activation of carotid sinus baroreceptors pause for 3 seconds → branch of glossopharyngeal nerve → medulla → sympathetic fibers
via vagus nerve → heart, vessels → AV block, vasodilation → hypotension, syncope?
```
Carotid Sinus Hypersensitivity
M >50
● Treatment
● Loosen clothing around the neck
● Pacemakers
CN 9, 10
```
62
How does micturition and autonomic control cause syncope?
Situational Syncope
M
Micturition
○ Abrupt change in position combined with strong vagal stimulus
● Abnormal autonomic control
○ Straining contributes to DEC BP by decreasing venous return
○INC ICP d/t INC intrathoracic pressure which DEC cerebral blood flow
CNX and spinal cord
63
What is MC cardiac cause and syncope has no warning?
Arrhythmias-
Bradyarrhythmia*
Tachyarrhythmias- palpitations (feel hurt beat)
64
THis cause what cardiac issue assoc with syncope, Intrinsic sinus node disease-sick sinus syndrome, drugs β-blockers, or autonomic imbalance
```
Sinus Bradycardia
Defect in conduction/generation
HR low, LOW CO
reoccurs
abrut onset
```
TX- Pacemaker
65
What type of AV block cause syncope
1st or 2nd degree
Benign or progressive
TX- pacemaker
66
Preceded by palpitations, lighthead, abrupt and WHat cause syncope and MC due to underlying structural heart disease, particularly CAD
Ventricular Tachy
Atrial flutter, atrial fibrillation
○ Bypass AV node conduction
TX- antiarrhytmic drugc
ICD
ablation
67
What causes syncope more often than disorganized rhythm disturbances?
Organized SVT
rare cause
TX- antiarrhytmic drug
ablation
68
Mr. Super c/c syncope, he has angina, orthostatic dyspnea;
PE- Laterally displaced PMI, palpable S4
Harsh, crescendo-decrescendo murmur at ***RSB, radiates to the neck. What could be cause of syncope?
Aortic Stenosis- 2 valve instead of 3 l/t obstructed BF, less perfusion
rarely present with syncope; often associated with exertion
TX- Valve replacement
69
Mr. Tubor c/c DOE, chest pain, syncope on exertion
PE-Harsh, crescendo-decrescendo systolic murmur best at **LSB, intensified with maneuvers that decrease LV volume
S4 at apex, may be palpable; maybe S3
● EKG: high QRS voltage, Q’s infero-lateral
● Echo: LVH, LV function, mitral leaflets
What is causing his syncope?
Hypertrophic Cardiomyopathy
RISK- **sudden cardiac death
Treatment is with β-blockers or calcium channel blockers
70
What is prognosis of syncope?
Etiology related
30% death 1st if CV related
Low reoccurrence
```
Syncope Predictive rules for serious cardiac rick w
CHF
HCT <30%
ABN EKG
Systolic BP<90
SOB
```
