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Dizziness (Pre-syncope (postural hypotension / postural dizziness (aka…
Dizziness
Pre-syncope
cardiac (arrhythmia, UA, vavular)
postural hypotension / postural dizziness (aka intracranial hypotension/TIA) = need neuro exam if persistent
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Autonomic dysfunction (DM neuropathy, parkinsons, RT to carotid NPC)
neurogenic/reflex syncope
vasovagal
- emotional stress, blood, needle, pain, prolong standing
situational
- micturition, straining BO, cough, lifting heavy weight
carotid hypersensitivity (turning head, shave, tight collar)
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vascular
intraluminal
hypovolemia
hypovolemia (poor oral intake, NVD, diuresis)
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luminal
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autonomic (PD, DM, adrenal insufficiency)
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Hypertension (from fluid overload. Med non compliance, pain)
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Vertigo (rhythmic movement/ fall to one side)
- worse with head movements
- nystagmus
Central
- persistent
- FND
- multidirectional, vertical, non-fatiguable gaze evoked nystagmus
- NO N/V
(brainstem/ cerebellar) Stroke/ TIA
- neck pain/aortic dissection
- dangerous Ds - dysarthria, dysphonia, dysphagia, diplopia, dysmetria
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vestibular migraine
(Hx of migraine + vertigo x 5 + headache with 1/2 episodes of vertigo + hearing reduced/full/tinnitus)
Diagnosis of exclusion
(antiemetic, stemetil, flunarezine for dizzyness)
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Drug/alcohol
- gentamicin causes acute vestibular syndrome + oscillopsia
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Peripheral
- improves (CNS compensates)
- N/V
- no FND
- can walk
- horizontal unidirectional fatiguable nystagmus
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Inner ear/middle ear infection
- vestibular neuritis/ labrynthitis (stemeil, maxolon can suppress compensation - give 3 days max + vestib rehab)
- ramsay hunt syndrome
Meniere's disease (dx of exclusion)
- 2 episodes, 20min each + sensorineural hearing loss
- diuretic + reduced salt intake
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HiNTS test -
differentiate central & vestibular neuritis in someone with hours of vertigo + nystagmus
Central cause (any one)
- head impulse: no corrective saccade (aka no nerve problem)
- nystagmus: multidirectional/bidrectional gaze-evoked nystagmus *do not fixate
- skew of test: ocular tilt or skew deviation (not very sensitive)
TiTrATE
- central dizzyness can worsen with head movement
- episodic vert syndrome (triggered) TRO CPPV
- EVS (spontaneous) TRO cardiac/vestibulobasilar insufficiency
meniere, reflex syncope, vestibular migraine
- acute vestibular syndrome (triggered) TRO head trauma/drugs
- AVS (spontaneous) TRO posterior fossa mass/stroke/dissection/AMI
vestibular neuritis, alcohol/thiamine deficiency
History
- what were you doing when the giddiness happened? (Turning head, getting up, reaching above your head for something/standing very long under hot sun)
- how long did each episode last?
*ALWAYS REFER ENT OUTPATIENT