Transcript Slide 1
Dr Manj Tawana
Tuesday 27 May 2014
This afternoon:
Introductions (1.30 – 1.40pm)
Learning objectives (1.40 – 1.50pm)
Small group work and re-convene (1.50 – 2.50pm)
Break (2.50 – 3.10pm)
Presentation (3.10 – 3.30pm)
Quick quiz, finish-up, anything else? (3.30 – 4.00pm)
Learning Objectives (SMART):
Group.
Individual.
Outside scope for today? Further learning?
Resources.
10 mins
Group work:
Elderly patient walks into your GP consulting room....
“Doctor I’ve been getting dizzy spells.”
10 minute consultation with patient.
Assessment? (history, examination, tests,
management, ?referral).
Differentials?
30 mins
Group work:
Present back....
30 mins
Dizziness
Non-specific term: sensation of altered orientation in
space.
Vertigo: hallucination of rotation or movement of
one's self or one's surroundings.
Dizziness is of little diagnostic value without trying to
elaborate further information.
If there is loss of consciousness then this defines the
term syncope.
Suggested that there are four types of dizziness.
Dizziness
Vertigo
commonest type – more than 50% of cases of dizziness in
primary care.
may be described as an illusion of movement (i.e., a false
sense of motion).
it is frequently horizontal and rotatory.
illusion of rotation may be of one's self or one's surroundings
may be associated with nausea, emesis, and diaphoresis.
cause may be central or peripheral.
when associated with nausea and vomiting, should look for a
peripheral rather than central cause
most cases can be diagnosed clinically and managed in the
primary care setting.
Dizziness
Lightheadedness
this is non-specific.
sometimes difficult to diagnose .
may be associated with panic attacks.
Presyncope
is due to cardiovascular conditions that reduce cerebral blood
flow.
Dysequilibrium
feeling of unsteadiness and instability.
causes include: peripheral neuropathy, eye disease, peripheral
vestibular disorders.
Dizziness
in addition the following conditions too may present
with dizziness...
psychiatric disorders
seizure disorders
motion sickness
otitis media
cerumen impaction
Dizziness
Multisystem failure – esp. elderly patients.
Polypharmacy
Poor eyesight
Cardiac problems
Cerebrovascular disease
BPPV
Burnt out meniere’s
Vestibular failure
Incomplete central compensation
Peripheral neuropathies
Muscle weakness
Arthritic joints
History – essential!
Vertigo
do you get the feeling of rotation?
do the surroundings spin around?
is there a tendency to fall to one side?
Dysequilibrium
are you having a feeling of unsteadiness?
Presyncope
do you feel faintish?
Lightheadedness
do you feel lightheaded?
History
onset and duration of the symptoms:
Few seconds:
peripheral causes: unilateral loss of vestibular function, acute
vestibular neuronitis, Meniere's disease.
Several seconds to a few minutes:
BPPV.
Several minutes to one hour:
TIA.
Several hours:
Meniere's disease, migraine, acoustic neuroma.
Days:
early acute vestibular neuronitis, CVA, migraine, MS.
History
precipitating factors:
spontaneous episodes
acute vestibular neuronitis, cerebrovascular disease, Meniere's
disease, migraine, MS.
changes in position of the head
acute labyrinthitis, BPPV, cerebellopontine angle tumour, MS.
standing up
postural hypotension.
History
associated symptoms, including:
deafness.
tinnitus.
otalgia .
a feeling of fullness in the ear.
discharge from the ear.
neurological symptoms.
any other medical problems:
vascular disease.
MS.
drug history, esp. ototoxic drugs.
cardiac disease, esp. arrhythmias.
Examination – history driven
History driven, may be normal at time of seeing patient!
Neurological: CNs, cerebellar (finger-nose) , Dix-
Hallpike.
Head and neck: carotids (neck bruits), arthritic C-spine
(abnormal proprioceptive signals), TMs.
Cardiovascular system: pulse, BP, carotids, arrhythmias.
Treatments...
Consider:
Labyrinthitis:
BPPV:
Meniere’s disease:
Acoustic neuroma:
Vert. insufficiency:
Prochlorperazine.
Epley manoeuvre, Brandt-Daroff
exercises, prochlorperazine.
Betahistine, prochlorperazine,
?refer.
Refer.
Modify risk factors – BP,
smoking, aspirin, statin?
BMJ Learning – Falls Quiz.
Individually, pairs.
Pre-test.
Post-test.
Finish-up, anything else?
Learning objectives?
Further learning?
Resources?
Thank you!
Good luck!