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C. Year 3: Elderly Medicine > The Dizzy Patient > Flashcards

The Dizzy Patient Flashcards

1
Q

Vertigo is typically defined as a sensation of movement like spinning. Is this a central or peripheral or both dysfunction?

A
  • both
  • central = CNS such as brain stem or cerebellum
  • peripheral = vestibular dysfunction
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2
Q

Pre-Syncope is a prodrome to syncope, which is a complete loss of consciousness that people are often aware of. Which of the following typically occurs in pre-syncope?

1 - pallor
2 - nausea
3 - sweating
4 - all of the above

A

4 - all of the above
- essentially due to a transient impairment of cerebral blood flow

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3
Q

What is the prevalence of dizziness in the UK in >65s?

1 - 3%
2 - 13%
3 - 30%
4 - 60%

A

3 - 30%
- dizziness can lead to distress, falls, injuries, anxiety, loss of independence, isolation, depression and more

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4
Q

What are the 2 functions of the vestibular system?

1 - balance
2 - spatial awareness
3 - hearing
4 - smell

A

1 - balance
2 - spatial awareness

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5
Q

What does otolith mean?

1 - greek for ear
2 - greek for ear stone
3 - greek for hearing loss
4 - greek for heavy

A

2 - greek for ear stone
- saccule and utricle contain otoconia membrane and otoconia on top of the otoconia membrane
- otoliths are calcium carbonate stones
- heavy weight means they move and drag the gelatinous matrix with it, allowing hair cells to detect movement in a specific direction

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6
Q

The ability to remain static is the role of the saccule and utricle, which contain endolymph which helps with balance. What is endolymph?

1 - fluid in bony labyrinth high in K+
2 - fluid in bony labyrinth high in Na+
3 - fluid in membranous labyrinth high in K+
4 - fluid in membranous labyrinth high in Na+

A

3 - fluid in membranous labyrinth high in K+

  • clear fluid located in the membranous labyrinth of the inner ear
  • contains high K+ (140 mEq/L) and low Na+ concentration (15 mEq/L)
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7
Q

The macula is contained within the utricle and is the balance receptor of the ear. The macula contain sensory mechanoreceptors that are supported by epithelial cells. What are these mechanoreceptors located in the macula called?

1 - oliths
2 - ampulla
3 - hair cells
4 - follicular cells

A

3 - hair cells
- type 1 and 2

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8
Q

The saccule and utricle are at aprox 90 degrees to one another and contain macula. Why is this important?

1 - allows hair cells to detect movement in vertical and horizontal planes
2 - able to detect motion only
3 - able to detect static position only
4 - all of the above

A

1 - allows hair cells to detect movement in vertical and horizontal planes

  • utricle macula = horizontal plane pointing up remember the boys name HUgh
  • saccule macula = vertical plane pointing out remember Very Small
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9
Q

The otolith organs contained within the utricle and saccule contain type I and II hair cells that are able to detect movement in the macula. What are the hair cells embedded in?

1 - mucus
2 - gelatinous matrix
3 - columnar epithelial cells
4 - ear wax

A

2 - gelatinous matrix
- called otolithic membrane

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10
Q

The utricle macula contains hair cells in the horizontal plane pointing up. Remember HUgh:
- H = horizontal
- U = utricle

What type of motion are the hair cells of the utricle able to detect?

1 - linear acceleration in a horizontal plane
2 - head tilt (left, right, forward)
3 - driving a car, sudden break and the head moves forward
4 - all of the above

A

4 - all of the above

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11
Q

The saccula macula contains hair cells in the horizontal plane pointing up. Remember Very Small:
- V = ventricle
- S = small

What type of motion are the hair cells of the saccula able to detect?

1 - vertical linear acceleration/deceleration
2 - moving up and down
3 - movement when in a lift, etc.
4 - all of the above

A

4 - all of the above

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12
Q

Label the image of the macula below using the names below:

  • cilia
  • supporting cells
  • vestibular nerve axons
  • gelatinous matrix
  • hair cell
  • otoliths
A

1 = otoliths
2 = gelatinous matrix
3 = cilia
4 = hair cell
5 = supporting cells
6 = vestibular nerve axons

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13
Q

The hair cells contain cilia that are able to detect horizontal (utricle) and vertical (saccule) acceleration. There are 2 types of cilia, one of which is much larger than the others, what are they both called?

1- stereocilia and epicillia
2 - stereocilia and macucillia
3 - kiniocillia and stereocilia
4 - kiniocillia and large kiniocillia

A

3 - kiniocillia and stereocilia

  • kiniocillia = 1 large in each hair cell
  • stereocilia = mulitple of these in each hair cell
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14
Q

In addition to the multiple sterocilia (small) and the singular kinocilium (large) on hair cells in the vestibular system there is something in-between each sterocilia (small) and the singular kinocilium (large) called tip links. When there is movement the otoliths that are on top of the gelatinous membrane drag the gelatinous membrane. As they drag the gelatinous membrane the hair cells inside also move. When the hair cells detect movement the tip links come into closer contact with the adjacent sterocilia and kinocilium. When this occurs what happens?

1 - tip links open mechanically gated Na+ channels
2 - tip links open mechanically gated Ca2+ channels
3 - tip links open mechanically gated Mg+ channels
4 - tip links open mechanically gated K+ channels

A

4 - tip links open mechanically gated K+ channels

- increased K+ causes depolarisation

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15
Q

In addition to the multiple sterocilia (small) and the singular kinocilium (large) on hair cells in the vestibular system there is something in-between each sterocilia (small) and the singular kinocilium (large) called tip links. When the hair cells detect movement the tip links come into closer contact with the adjacent sterocilia and kinocilium. When this occurs tip links open mechanically gated K+ channels and increased K+ causes depolarisation. What then happens at the base of the hair cell?

1 - depolarisation of the hair cell causes Ca2+ release at the bottom of the hair cells
2 - Ca2+ causes vesicles containing glutamate to fuse with membrane, releasing glutamate
3 - glutamate (stored in vesicles) is released into synaptic space
4 - glutamate binds to glutamate receptors and depolarises the axon, sending a signal to the brain
5 - all of the above

A

5 - all of the above

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16
Q

Which cranial nerve supplies the vestibular system?

1 - vagus nerve (X)
2 - trigeminal nerve (VII)
3 - vestibulocochlear (VIII)
4 - assessory nerbe (XI)

A

3 - vestibulocochlear (VIII)- cranial nerve VIII (8) vestibulocochlear nerve
- vestibular branch

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17
Q

When our heads are in a stationary position we are constantly generating action potentials to tell the brain about our head position. However, if we change position and move towards or away from the kinocilium, do the action potentials increase or decrease?

A
  • towards = increased action potentials
  • away = decreased action potentials
  • tells the body about position
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18
Q

Why are the semi-circular canals arranged at 90 degrees to one another?

1 - allow horizontal and verticle motion awareness
2 - allow 3 dimensional motion awareness
3 - ensure awareness of being stationary and moving
4 - allows the ability to remain stationary

A

2 - allow 3 dimensional motion awareness

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19
Q

There are 3 semi-circular canals which are continuations of the utricle. What are the 3 positions (names) of the canals?

1 - superior, posterior and inferior
2 - superior, inferior and lateral
3 - anterior, posterior and lateral
4 - lateral, medial and inferior

A

3 - anterior, posterior and lateral

  • anterior (like handle on a handbag)
  • posterior (like handle on a mug)
  • lateral (like a shelf draw pulling out)

Together they provide 3 dimensional information

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20
Q

The semicircular canals are continuations of the utricle, and therefore contain the same fluid, which is called what, endolymph or perilymph?

A
  • endolymph
  • high in K+ and low in Na+
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21
Q

The semicircular canals are continuations of the utricle, and therefore contain the same fluid, called endolymph. There is also an enlarged portion at the end of each of the semi-circular canals (so 3 in total), called what?

1 - macula
2 - canaliculi
3 - fossa
4 - ampulla

A

4 - ampulla
- allows us to detect changes in head rotation

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22
Q

In the ampulla is the crista ampullaris, which is the sensory organ that is able to detect rotation and angular acceleration and deceleration. What is contained within the crista ampullaris?

1 - cisterna
2 - hair cells type I and II
3 - Ca2+ channels
4 - otoliths

A

2 - hair cells type I and II
- a gelatinous mass called the capula that covers hair cells

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23
Q

In the ampulla is the crista ampullaris, which is the sensory organ that is able to detect rotation and angular acceleration and deceleration. Within the crista ampullaris are hair cells type I and II covered in a gelatinous mass called the cupula. Each hair cell is the same as those contained within the saccula and utricle, meaning they have lots of sterovilli, one kinocilium and tip links that connect sterovilli and the kinocilium. What happens if the hair cells are stimulated and the sterovilli and the kinocilium move towards a stimulus?

  • tip links open mechanically gated K+ channels
  • K+ causes depolarisation
  • depolarisation causes Ca2+ channels to open
  • Ca2+ causes the release of glutamate into synaptic space
  • glutamate binds to receptors causing action potential to be sent to the brain
  • all of the above
  • via cranial nerve VIII (8) the vestibulocochlear
A
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24
Q

When the hair cells are stimulated inside the crista ampullaris contained in ampulla is the sterovilli and the kinocilium move towards a stimulus. This inturn triggers an action potential that is sent to the brain and informs us about this change in head position. Which crnail nerbve is responsible for delivering this information?

1 - vagus nerve (X)
2 - trigeminal nerve (VII)
3 - vestibulocochlear (VIII)
4 - assessory nerbe (XI)

A

3 - vestibulocochlear (VIII)

25
Q

Projections of the 4 regions of the vestibular nuclei (inferior, superior, lateral and medial) are able to innervate which cranial nerves?

1 - CNs I, II and III
2 - CNs II, III and IV
3 - CNs III, IV and VI
4 - CNs IV, VI and X

A

3 - CNs III, IV and VI

  • cranial nerve III (3) (oculomotor nerve)
  • cranila nerve IV (4) (trochlear nerve)
  • cranial nerve VI (6) (abducens nerve)
  • contribute towards coordinating the eye, neck and trunk movement.
26
Q

When looking at the semi-circular canals of the vestibular system, which are filled with endolymph, if we move our head and look to the right, does the endolymph move in the same direction to the right or to the left?

A
  • opposite
  • so endolymph moves to the left
27
Q

When we turn our head to look to the right the endolymph within the lateral semi-circular canals of the vestibular system will move in the opposite direction. How does this link with out eye position?

A
  • the right vestibular nuclei decussate to left hemisphere
  • the efferent signal innervates the abducens nuclei of cranial nerve VI (6) (abducens nerve)
  • cranial nerve VI (6) signals the left lateral rectus muscle to contract and eye moves to the left
28
Q

When we turn our head to look to the right the endolymph within the lateral semi-circular canals of the vestibular system will move in the opposite direction. The right vestibular nuclei decussates to the left hemisphere and the efferent signal innervates the abducens nuclei of cranial nerve VI (6) (abducens nerve) and contracts the left lateral rectus muscle to contract and eye moves to the left. How does this also contribute to the right eye?

A
  • interneurons from the abducens muscle decussation to right side of hemisphere
  • signals for the right cranial nerve III (3) the occulomotor nerve to contract the right medial rectus
29
Q

Nystagmus has 2 phases, what are they?

1 - delayed phase
2 - slow phase
3 - stationary phase
4 - fast phase

A

2 - slow phase
- slow eye movement in opposite direction

4 - fast phase
- rapid eye movement to jump back to same direction

- fast phase =

30
Q

Nystagmus has 2 phases:

  • slow phase = slow eye movement in opposite direction
  • fast phase = rapid eye movement to jump back to same direction

If nystagmus occurs in the absence of head movement, this can indicate damage to where?

1 - vestibular nerve
2 - cerebellum
3 - pons
4 - brain stem

A

1 - vestibular nerve

31
Q

Vertigo can be caused by central and peripheral effects. Which peripheral effect can cause vertigo?

1 - vestibular dysfunction
2 - cochlear duct
3 - oval window
4 - cochlea

A

1 - vestibular dysfunction
- can be caused by accumulation of debris from otolithic membrane to the ampulla
- sensitivity is increased to angular movement, affecting balance
- causes nausea and/or vomiting

32
Q

Which of the following is NOT a typicalk cause of dysfunction of the vestibular system that can lead to vertigo?

1 - ear infection
2 - trauma
3 - epistaxis
4 - inflammation of the membranous labyrinth
5 - ototoxity caused by drugs

A

3 - epistaxis
- medical name for nose bleed

33
Q

Meniere’s disease is a condition that affects the inner ear, and ultimately the vestibular system. Meniere’s disease is a rare condition affecting the inner ear. Which of the following can occur in Meniere disease?

1 - accumulation of endolymph due to poor drainage that makes ears feel full
2 - damage to hair cells and inability to detect movement
3 - tinnitus
4 - vertigo that is intermittent and relapsing
5 - all of the above

A

5 - all of the above
- typically includes the triad:

1 - vertigo
2 - tinnitus
3 - sensorineural hearing loss

34
Q

Which of the following inputs does NOT contribute to balance?

1 - proprioception (fast response)
2 - cochlea system (fast response)
3 - vestibular system (fast response)
4 - vision (slow response)

A

2 - cochlea system (fast response)
- important in hearing but not balance

35
Q

The cerebellum is part of the integration of information related to balance. What is the key role of the cerebellum in balance?

1 - regulates posture, movement and balance
2 - contributes higher thinking and memory
3 - integrates and processes sensory information
4 - all of the above

A

4 - all of the above

36
Q

The cerebral is part of the integration of information related to balance. What is the key role of the cerebral in balance?

1 - regulates posture, movement and balance
2 - contributes higher thinking and memory
3 - integrates and processes sensory information
4 - all of the above

A

2 - contributes higher thinking and memory

37
Q

The brainstem is part of the integration of information related to balance. What is the key role of the brainstem in balance?

1 - regulates posture, movement and balance
2 - contributes higher thinking and memory
3 - integrates and processes sensory information
4 - all of the above

A

3 - integrates and processes sensory information

38
Q

As we age our balance declines, which is due to a number of factors. Which of the following have been shown to occur in ageing?

1 - impaired vestibular function
2 - peripheral neuropathy
3 - visual impairment
4 - slower central processing
5 - reduced muscle mass and strength
6 - all of the above

A

6 - all of the above

  • hair cells have been shown to decline with age
39
Q

When assessing a patient with balance issues, history is really important. Which of the following is NOT a relevant factor in a patient reporting dizziness?

1 - describe what is meant by dizziness
2 - continuous, intermittent and duration
3 - features of dizziness are present (vertigo, pre-syncope)
4 - any fall history
5 - family history
6 - medications

A

5 - family history
- can be relevent, such as Meniere disease, but not crucial when asking about the dizziness

40
Q

When performing an neurological examination in a patient with balance issues. which of the following should be performed?

1 - eye movements
2 - cerebellar examination
3 - peripheral sensation
4 - gait
5 - all of the above

A

5 - all of the above

41
Q

Which 2 of the following should be routinely conducted during an examination in a patient with dizziness?

1 - lying/standing BP
2 - echocardiogram
3 - chest X-ray
4 - cardiac auscultation

A

1 - lying/standing BP
4 - cardiac aus

42
Q

There are lots of different causes of dizziness. Which of the following is the most common cause?

1 - CNS (migraine, cerebrovascular disease)
2 - cardiovascular
3 - multi-sensory impairment
4 - psychogenic
5 - other undiagnosed causes
6 - peripheral vestibular dysfunction

A

6 - peripheral vestibular dysfunction

43
Q

The most common cause of dizziness is peripheral vestibular dysfunction. Which of the following is NOT a type of peripheral vestibular dysfunction?

1 - benign paraoxysmal position vertigo
2 - migraine
3 - menieres disease
4 - vestibular neuritis/labyrinthitis

A

2 - migraine
- form of CNS issue

44
Q

There is a broad range of contributing factors that can lead to pre-syncope. Which of the following is NOT typically a cause of pre-syncope?

1 - cardiac arrhythmias (AF)
2 - structural cardiac changes (aortic stenosis, hypertrophic cardiomyopathy)
3 - congestive heart failure
4 - autonomic dysfunction (vaso-vagal, autonomic failure)

A

3 - congestive heart failure

45
Q

There is a broad range of contributing factors that can lead to pre-syncope. Which of the following can cause pre-syncope?

1 - volume depletion
2 - vasodilation (sepsis)
3 - medications
4 - situational (cough, micturation, post-prandial)
5 - steal syndromes
6 - all of the above

A

6 - all of the above

46
Q

When treating a patient, which pre-syncope, should medication be reviewed?

A
  • yes
  • some medication may need to be stopped (diuretics, alpha blockers)
47
Q

A head impulse, nystagmus and test of skew (HINTS) examination can be used to try and distinguish between a central and peripheral cause for pre-syncope. Which of the following is NOT part of the criteria to perform a HINTS test?

1 - persistent vertigo over hours or days
2 - nystagmus
3 - normal full neurological exam in presence of pre-syncope symptoms
4 - >65 y/o

A

4 - >65 y/o
- HINT test should be performed when the patient is symptomatic

48
Q

The head impulse, nystagmus and test of skew (HINTS) examination can be used to try and distinguish between a central and peripheral cause for pre-syncope. Which of the following are true about the head impulse aspect of the HINTS examination?

1 - positive test = patient unable to maintain fixation on examiners point
2 - following rapid movement the eyes do not fix on examiners point, but are able to saccade rapidly back to the point of fixation on the clinician’s nose (a ‘corrective saccade’).
3 - patients must be symptomatic when test is performed
4 - all of the above

A

4 - all of the above

49
Q

The head impulse, nystagmus and test of skew (HINTS) examination can be used to try and distinguish between a central and peripheral cause for pre-syncope. Id the test is positive, does this suggest a central or peripheral issue?

A
  • peripheral
  • vestibulocochlear nerve damage on the ipsilateral side (peripheral issue) is likely to be damaged
50
Q

The head impulse, nystagmus and test of skew (HINTS) examination can be used to try and distinguish between a central and peripheral cause for pre-syncope. Which of the following are true about the nystagmus aspect of the HINTS examination?

1 - unidirectional nystagmus is more likely to be of peripheral origin
2 - change in nystagmus direction is likely to be associated with central pathologies.
3 - bidirectional nystagmus, is highly specific for stroke.
4 - all of the above

A

4 - all of the above

51
Q

The head impulse, nystagmus and test of skew (HINTS) examination can be used to try and distinguish between a central and peripheral cause for pre-syncope. This can often show abnormal movements associated with vertical diplopia. Is this specific to CNS or peripheral damage?

A
  • indicative of CNS
52
Q

All of the following are causes of vertigo. Which of the following is the most common cause of vertigo?

1 - stroke
2 - labyrinthitis
3 - vestibular neuritis
4 - benign paroxysmal positional vertigo
5 - manieres disease

A

4 - benign paroxysmall positional vertigo

53
Q

Benign paroxysmall positional vertigo (BPPV) is the most common cause of paroxysmall vertigo. Which of the following is NOT true about BPPV?

1 - all ages can be affected, but elderly most
2 - believed to be debris from otoliths and become lodged in utricular maculae and trapped in semi-circular canals
3 - brief paroxysms of vertigo and nausea/vomiting can be induced by head movements
4 - vertigo settles with continued movement
5 - nystagmus accompanies vertigo

A

4 - vertigo settles with continued movement
- incorrect

  • vertigo settles with complete stillness
54
Q

Benign paroxysmall positional vertigo (BPPV) is the most common cause of paroxysmall vertigo. Which of the following tests is used to diagnose of BPPV?

1 - HINT test
2 - DIX-Hallpike test
3 - Epley manoeuvre
4 - any of the above

A

2 - DIX-Hallpike test
- also confirms the side of the dysfunction

55
Q

Benign paroxysmall positional vertigo (BPPV) is the most common cause of paroxysmall vertigo. Which of the following tests can be used to monitor the efficacy of a treatment in BPPV?

1 - HINT test
2 - DIX-Hallpike test
3 - Epley manoeuvre
4 - any of the above

A

3 - Epley manoeuvre
- essentially a positive DIX-Hallpike test means we need to then do the Epley manoeuvre

56
Q

Labyrinthitis and vestibular neuritis is inflammation that is associated with Upper respiratory tract infections that causes vertico. Which of the following are true about Labyrinthitis and vestibular neuritis?

1 - hearing loss and tinnitus are common
2 - symptoms are continuous and last days to weeks
3 - vertigo worsened but not precipitated by head movement
4 - symptoms typically subside spontaneously after a few weeks with no treatment required.
5 - all of the above

A

5 - all of the above

57
Q

Vestibular rehabilitation can be used in patients with vertigo, including:

  • habituation gazing
  • gaze stabilisation exercise
  • balance training

Are these rehabilitation exercises useful?

A
  • yes
  • have been shown to be effective at reducing falls and improving quality of life
58
Q

In patients with vertigo, medications may be considered. Which one of the following medications is most commonly used in a patient with vertigo?

1 - Metoclopramide
2 - Chlorpromazine
3 - Ondansetron
4 - Cyclizine

A

4 - Cyclizine
- H1 receptor blocker, which is present on the H1 receptors of the vestibular nuclei and the vomiting centre

  • Metoclopramide + Chlorpromazine = D2 receptor antagonist
  • Ondansetron = 5-HT3 receptor antagonists

C. Year 3: Elderly Medicine (18 decks)

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