Symptom To Diagnosis - Dizziness Flashcards
Vertigo - Chief complaint:
Spinning.
Near syncope - Chief complaint:
Nearly fainting.
Dysequilibrium - Chief complaint:
Falling, loss of balance.
Non specific dizziness - Chief complaint:
Floating vague.
Vertigo - Typical precipitants:
Turning over in bed.
Looking up to shelf.
Near syncope - Typical precipitant:
Standing.
Dysequilibrium - Typical precipitant:
Walking.
Non specific dizziness - Typical precipitant:
Stress.
Vertigo - Important historical clues:
Attack duration.
CNS signs or symptoms (dysarthria, ataxia, diplopia, headache, neck pain).
Peripheral symptoms –> Hearing loss, tinnitus.
Near syncope - Important historical clues:
- CAD HF.
- History of syncope.
- Palpitations.
- Medications.
- Melena or rectal bleeding.
Dysequilibrium - Improtant historical clues:
- Diabetes.
- Neuropathy.
- Visual problems.
- Imbalance.
- Medications.
Non specific dizziness - Important historical clues:
- Multiple somatic complaints.
- Feeling down or hopeless.
- Anhedonia.
Vertigo - Key exam physical findings:
- Cranial nerve exam.
- Gait.
- Finger-to-nose exam.
- Dix-Hallpike maneuver.
Near syncope - Key physical exam findings:
- Orthostatic blood pressure and pulse.
2. Cardiac exam.
Dysequilibrium - Key physical exam findings:
- Gait.
- Sensation.
- Position sense.
- Cranial nerve exam.
- Finger to nose exam.
Vertigo - DDX:
PERIPHERAL –> BPPV, vestibular neuritis, Meniere.
CENTRAL –> CVA, MS, Cerebellar hemorrhage, migraine, Brainstem Tumors.
Near syncope - DDX:
- Dehydration.
- Hemorrhage.
- Orthostatic hypotension.
- Vasovagal reflexes.
- Arrhythmias.
- Hypoglycemia.
- Aortic stenosis.
- PE.
Dysequilibrium - DDX:
- Multiple sensory deficits.
- Parkinson disease.
- Cerebellar degeneration or stoke.
- B12 def.
- Tabes dorsalis.
- Myelopathy.
Non specific dizziness - DDX:
- Depression.
- Generalized anxiety disorder.
- Panic attacks.
- Somatization disorder.
MCC of dizziness:
Vertigo.
About …% of vertigo patients have peripheral etiology.
90%.
Peripheral vertigo:
- BPPV.
- Labyrinthitis or vestibular neuritis.
- Meniere.
- Uncommon –> Head trauma, herpes zoster.
Central vertigo:
- CVA.
- Cerebellar degeneration.
- Migraine.
- MS.
- Alcohol intoxication.
- Phenytoin toxicity.
- Tumors of the BRAINSTEM or cerebellum.
Central vertigo - CVA:
- Vertebral insufficiency.
- Cerebellar or Brainstem stroke.
- Cerebellar hemorrhage.
- Vertebral artery dissection.
Near syncope is a common cause of dizziness particularly in the …?
Elderly.
Dysequilibrium - Etiologies:
- Multiple sensory deficits.
- Parkinson disease.
- Normal-pressure hydrocephalus.
- Cerebellar disease (degeneration, tumor, infarction).
- Peripheral neuropathy (diabetes).
- Dorsal column lesions (B12, syphilis, compressive lesions).
- Drugs.
Drugs that may cause dysequilibrium:
- Alcohol.
- Benzodiazepines.
- Anticonvulsants.
- Aminoglycosides.
- Antihypertensives.
- Muscle relaxants.
- Cisplatin.
Non specific dizziness - Etiologies:
- Psychological –> Major depression, anxiety, panic disorders, somatization disorders.
- Recently corrected vision –> New glasses, Cataract removal.
- Medication side effect.
Features suggesting CENTRAL vertigo?
- CNS signs.
- CNS symptoms.
- Severe headache or neck pain.
- Significant imbalance.
- CEREBROVASCULAR risk factors.
BPPV - Textbook presentation:
Abrupt onset of severe dizziness –> The room is spinning.
- -> They often describe it as feeling like the room is spinning.
- -> They often note that the symptoms began when they rolled over in bed, looked up (to get something out of the closet), or bend down to tie their shoes.
BPPV - Duration of symptoms:
Each episode is brief (10-20 sec) rather than persistent (as in vestibular neuritis).
However, since the episodes occur in clusters, patients often complain of vertigo that occurs for days to weeks.
BPPV - Vertigo precipitated by?
Positional changes.
BPPV is 2o to?
Free-floating canalith usually within posterior semicircular canal.
–> Precipitant is usually unknown, although BPPV may follow labyrinthitis or head trauma.
EBD of BPPV - Criteria:
- Recurrent vertigo.
- Duration of attack <1min.
- Symptoms invariably provoked by changing head position.
- Not attributable to another disorder.
BPPV criteria - Symptoms provoked by changing head position?
- Lying down or turning over in bed or
2. 2 of the following: Reclining the head, rising from supine, or bending forward.
EBD of BPPV - Patients with all 4 criteria?
Sens - 88%.
Spec - 92%.
LR+ 11.
LR- 0.13.
One study reported that ALL patients with BPPV complained that the vertigo was?
Provoked by turning over in bed.
EBD of BPPV - …% complained of imbalance, but falling was rare (…/…) and should raise the concern of another disorder.
50%.
1/61.
What type of nystagmus does BPPV have and how is it precipitated?
- Nystagmus usually begins after a few seconds, is brief (<30sec), and fatigues with repetition of maneuver.
- Sens 42-78%.
- Spec 94%.
- Nystagmus that begins immediately, lasts longer than 1 minute or fails to fatigue suggests a central (brainstem) disorder.
EBD of BPPV - When to perform CNS imaging?
CNS imaging should be performed in patients with findings that suggest central disease and in patients with atypical findings for BPPV.
Acute vestibular neuritis - Textbook presentation:
Typically presents ABRUPTLY with severe CONSTANT vertigo and nausea made worse by head turning that lasts for days.
–> Subsequently, patients may complain of INTERMITTENT vertigo that occurs for weeks to months and is precipitated by head movement.
Acute vestibular neuritis may follow?
Viral infection involving the vestibular nerve and the labyrinth.
Acute vestibular neuritis - Nystagmus:
Patients often have spontaneous vestibular nystagmus that is unilateral, horizontal, or horizontal and torsional and suppressed by visual fixation.
Acute vestibular neuritis - Nausea and vomiting are?
Common.
Acute vestibular neuritis - How long does the vertigo last?
2-3 days. May last up to 1 week.
Ramsay-Hunt syndrome?
Variant of vestibular neuritis.
- -> VZV reactivation involving cranial nerves VII and VIII produces vestibular neuritis with hearing loss and facial weakness.
- -> VESICLES are seen in the external auditory canal.
EBD - Acute vestibular neuritis:
- Clinical diagnosis.
2. Cerebellar infarction may present like vestibular neuritis and needs to be carefully considered.
EBD of Acute vestibular neuritis - When to perform an MRI?
- Headache.
- Weakness.
- Dysmetria.
- Inability to ambulate.
- Cranial nerve findings.
- Skew deviation.
- Nystagmus which is not suppressed by visual fixation.
- Risk factors for vascular disease.
- Persistence of severe vertigo beyond a few days.
Meniere disease - Textbook presentation:
Patients complain of INTERMITTENT vertigo. They may note ear fullness, unilateral hearing loss, and tinnitus.
Spells typically last for minutes to hours (rarely longer than 4-5 hours) and occasionally up to a day.
Meniere disease - Disease highlight:
Excess fluid in the endolymphatic spaces of the inner ear.
EBD of Meniere - Diagnostic criteria:
Requires the following for a definite diagnosis:
- Two spontaneous episodes of vertigo lasting >20min.
- Confirmed sensorineural hearing loss.
- Tinnitus or perception of aural fullness, of both.
EBD of Meniere - Rule out syphilis:
Test should be done to rule out syphilis (FTA-Ab).
Migraine - Textbook presentation:
Sufferers complain of intermittent attacks of severe unilateral throbbing headache associated with:
- Photophobia.
- Phonophobia.
- Nausea.
- Vomiting.
- -> Headaches may be preceded by a visual aura (scotoma or scintillating lights).
- -> Occasionally: Vertigo.
Suggested criteria for migrainous vertigo:
- Recurrent episodic vertigo.
- Current or prior history of migraine.
- One of the following symptoms during at least 2 vertiginous attacks:
- -> Migrainous headache.
- -> Photophobia.
- -> Phonophobia.
- -> Visual or other auras.
Migrainous vertigo - Duration:
May last several hours or days and may be spontaneous or positional.
EBD of migrainous vertigo - Sequence of events:
In patients with vertigo due to migraine, vertigo may precede, be concurrent with, or temporally unrelated to headache.
EBD of migrainous vertigo - Correlation of vertigo and headache:
45% –> Vertigo regularly associated with headache.
48% –> Vertigo occurs with AND without headache.
6% –> Vertigo and migraine did NOT occur together.
Cerebellar hemorrhage - Textbook presentation:
ABRUPT onset of headache associated with vomiting, ataxia, and vertigo.
Cerebellar hemorrhage - Occurs with?
Exertion or at rest.
Cerebellar hemorrhage accounts for …-…% cases of intracerebral hemorrhages.
5-16%.
Cerebellar hemorrhage - Etiology - Common etiologies:
- Hypertensive hemorrhage.
- Subarachnoid hemorrhage.
- Amyloid angiopathy.
- AV malformations.