VERTIGO/DIZZINESS/SYNCOPE

Question 1

A patient presents to the office complaining of dizziness, what are some other associated symptoms you should ask about?

Answer 1

Changes in vision, LOC, & orthostasis

Question 2

If a patient has orthostasis, how would their blood pressure change?

Answer 2

When they stand, systolic BP falls >20 & diastolic falls >10; HR increases 10-25

*lie for 10 minutes, stand for 2 minutes and THEN test

Question 3

What are the meds that we can use to treat orthostasis?

Answer 3

Iatrogenic or mineralcorticoid (fludrocortisone)

Question 4

What occurs before someone faints or has a syncopal episode?

Answer 4

Prodrome

Question 5

What are the 3 types of syncope?

Answer 5

Cardiac, neurological, and simply fainting (anxiety/stress)

Question 6

What must you ask about in your history?

Answer 6

history of heart disease, medications, and if a seizure occurred

Question 7

What are some of the cardiac causes for syncope?

Answer 7

Arrhythmia, heart block, aortic stenosis

Question 8

What is the cardiac syncope workup?

Answer 8

Echocardiogram, EP study, EKG

Question 9

How do you treat true cardiac syncope?

Answer 9

Defibrillator or anti-arrhythmic

Question 10

If a patient says the room is spinning or that they are spinning, what diagnosis?

Answer 10

Vertigo

Question 11

What are some of the causes of vertigo?

Answer 11

Vestibular system, inner ear disturbance, altered head position (damage to CN VIII)

Question 12

What is involved in maintaining normal balance?

Answer 12

Visual input, somatosensory input (skin, joints, muscles, spinal cord), cerebellum, and cerebrum

Question 13

What PE finding often occurs in the eyes with vertigo?

Answer 13

Nystagmus

Question 14

What are the 2 types of vertigo?

Answer 14

Physiologic & Pathologic

Question 15

What are some examples of physiologic vertigo?

Answer 15

abnormal input to stabilize (car sickness), unfamiliar/unusual head position (sea sickness or painting ceiling), spinning

Question 16

What are some examples of pathological vertigo?

Answer 16

disturbance of vision, somatosensory system, vestibular system, CNS, worse with rapid head movement.

Question 17

What are some of the etiologies of vertigo?

Answer 17

idiopathic (acute labrynthitis), infection (herpes), trauma, ischemia, drugs (alcohol, aminoglycosides)

Question 18

What are the 3 most common special causes of vertigo?

Answer 18

Meniere’s, cranial nerve (VIII), and BPV

Question 19

If a patient presents with tinnitus and dizziness with low frequency hearing loss, what diagnosis? Affecting what part of the ear?

Answer 19

Meniere’s

Cochlear

Question 20

What is pathoneumonic for meniere’s disease?

Answer 20

Low frequency hearing loss – most people lose their high frequency first

Question 21

How would you treat Meniere’s disease?

Answer 21

Diuretics (HCTZ) and very low salt restriction

Question 22

If a patient has unilateral hearing loss, tinnitus, and balance problems (to the same side as the hearing loss)?

Answer 22

Cranial Nerve VIII – acoustic neuroma

Question 23

How do you confirm Cranial Nerve VIII?

Answer 23

MRI – looking for an acoustic neuroma

Question 24

If a patient has dizziness with a specific head position?

Answer 24

benign positional vertigo (BPV)

Question 25

How would you treat BPV?

Answer 25

Epley’s maneuver

Question 26

What should you always do when evaluating a patient with dizziness?

Answer 26

H&P, orthostatic vital signs, cardiac testing, and provocative tests (head shaking, special glasses)

Question 27

What does the cardiac testing involve?

Answer 27

EKG, Echo, holter monitor, event monitor, exercise stress test (low yield), electrophysiologic study, tilt table test

Question 28

How do you treat vertigo?

Answer 28

Treat cause (if known), bed rest, vestibular rehabilitation, medications

Question 29

What type of medications can you use for vertigo (not sea sickness or motion sickness)?

Answer 29

Vestibular suppressants (meclizine), Benzodiazepines (diazepam), steroids, epley maneuver

Question 30

What medications can you use for sea sickness & motion sickness?

Answer 30

Dramamine & Scopalamine patch