2. Dizziness VertigoPresyncopeDisequilibriumLight headedness DescriptionIllusion of movement, usually rotatory of self or surrounding Sensation of impending loss of consciousness Postural unsteadiness, imbalance when standing Also called ‘dizziness’, ‘giddiness’ or ‘wooziness’. No clear definition Clinical significance A wide range of possible causes requiring further assessment Reduction of total cerebral blood flow, usually of cardio- vascular origin Presence of syncope exclude peripheral causes of dizziness Neurological disorder, musculoskeletal weakness or visual impairment This term is now used interchangeably with presyncope 2

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4. Vertigo is a hallucination of movement of the environment about the patient, or of the patient with respect to the environment caused by disorders of the labyrinth or brainstem. Peripheral vertigo (labyrinth, vestibular nerves) Central vertigo (CNS)Other Common: Acute vestibulopathy: vestibular neuritis or labyrinthitis, BPPV, Meniere disease TIA or stroke (PICA), especially if Vertebrobasilar system affected, Cerebellitis Psychogenic vertigo, Cervical vertigo Rare: Perilymphatic fistula, Herpes zoster, Cholesteatoma erosion, Otosclerosis, Motion sickness Multiple sclerosis, Cerebellopontine angle tumour Medication: aminoglycoside, furosemide, antidepressants, alcohol and antipsychotics 4

5. Margaret aged 69 years comes to see you in your GP clinic. She has three-day history of sudden episodes of dizziness. She describes the dizziness as room is spinning when sitting up after waking, a sense of falling backward when attempting to lie on bed and room spinning when rolling over the bed. She also describes rotatory sensation during the day predicated by opening a high cupboard, or hanging out washings on cloth line. She had been in good general health and had no past history of head injury. She is not taking any medications regularly and had no known allergies. Your tasks are: ■To take a focused history. ■To explain to the examiner what differential diagnostic thoughts go through your mind. ■To perform a physical examination and explain to the examiner what you are looking. ■To explain the most likely diagnosis, further investigations and management to the patient. 5

6. History ■GM, I am Dr. Kalsi, how can I help you today? What do you mean by vertigo? Is it vertigo or pseudovertigo? Since when? Duration? Is Paroxysmal or continuous? How often do you get this feeling? Is it the first time? Is it progressing? What makes it better/worse? Effect of position and change of posture? ■Nausea, vomiting-very important. Any aural symptoms such as tinnitus (ringing in your ears) or deafness or pain in the ears? Have you had any flu recently? Recent colds? Any history of head injury? ■Have you noticed any asymmetry of Face? Any associated weakness (or Numbness / tingling) in your Arms or legs? Any trouble with Speech. Sight (diplopia, blurring), Swallowing? ■Chest pain? Racing of heart? SOB? Palpitations? ■Any changes in weight or appetite? – tumour. Do you have any pain in the neck? ■Are you driving at he moment? Any trouble with it. ■Drugs (alcohol, marijuana, hypotensive, psychotropics, others?) General medical and surgical history. SADMA? FHx 6

7. Physical examination ■General appearance. BMI, ■Vital signs: look for postural hypotension- very important, fever ■Eyes: visual acuity and nystagmus ■ENT: hearing tests and Otoscopic examination may reveal signs of inflammation associated with acute vestibulopathy, scarring of the eardrum from chronic suppurative otitis media, or an erosive cholesteatoma. ■Facial asymmetry. ■CVS: atherosclerosis: Carotid Bruit ■Cranial nerves: ROM, 2 nd, and 7 th and 8 th. Cerebellum: gait, coordination, reflexes, Romberg test, finger-nose tests ■Neck: cervical spine ■Dix-Hallpike Maneuver for BPPV 7

8. Dix-Hallpike manoeuvre: Make sure there is no head or neck injury!!! From a sitting position, the patient’s head is rapidly taken to a head hanging position 45 below the level of the couch, 45 degrees to the side – do three times with head straight, rotated to the right, rotated to the left  hold for 30 seconds and observe for vertigo and nystagmus. The Dix-Hallpike manoeuvre is performed for diagnosis and the Epley manoeuvre is used for treatment of benign paroxysmal positional vertigo (BPPV). 8

9. Management ■Margaret, I think you are having a condition called Benign paroxysmal position vertigo which is characterized by sudden spinning sensation of the head when head is moved. BPPV is the most common cause of vertigo. It is more common in females (F:M ratio is 2:1). ■I will explain how this occurs. Our inner ear contains the organs of balance that keeps us steady. BPPV is thought to be caused by deposition of little calcium crystals (otoconia) within these organs of balance. Cause is unknown but can follow accidents causing neck or head injuries in some people. ■Don’t worry it is a manageable condition. Usually, symptoms usually resolve spontaneously within 1–2 weeks, but may persist for up to several months. Avoid head positions that provoke the attack. ■I will give you some anti-motion sickness tablets (promethazine (Phenergan), prochlorperazine (stemetil). ■Do special exercise i.e. Epley’s Exercise.

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11. Epley maneuver: dislodge the debris in the labyrinth and restore balance. Deliberately carrying out the movements that provoke vertigo will eventually “fatigue” the symptomatic response. How to do the Epley maneuver: Requirements: a bed or table that can be accessed from both sides and which allows for the patient’s head to be positioned off the end of the table. A bowl is advisable in case of vomiting. 11

12. James aged 53 years presents to your GP clinic with history of severe dizziness and vomiting. This happened this morning and lasted for about 20 minutes. There is no past history of such episodes in the past even with his previous migraine attacks. James had background history of hypertension, hypercholesterolemia, impaired GTT and migraine. He is a heavy smoker for the last 30 years. James runs his own business and is always busy. He lives by himself in an independent accommodation and is well otherwise. Task ■Further focused history ■Physical Examination ■Differential diagnosis and management 12

13. History ■GM, I am Dr. Kalsi, how can I help you today? What do you mean by vertigo? Is it vertigo or pseudovertigo? Since when? Duration? Is Paroxysmal or continuous? How often do you get this feeling? Is it the first time? Is it progressing? What makes it better/worse? Effect of position and change of posture? ■Nausea, vomiting-very important. Any aural symptoms such as tinnitus (ringing in your ears) or deafness or pain in the ears? Have you had any flu recently? Recent colds? I had a flu a few days ago. Any history of head injury? ■Have you noticed any asymmetry of Face? Any associated weakness (or Numbness / tingling) in your Arms or legs? Any trouble with Speech. Sight (diplopia, blurring), Swallowing? Did you lose consciousness/confusion? Change in gait? Is he able to walk? ■Chest pain? Racing of heart? SOB? Palpitations? Vomiting? Waterworks? Bowel motions? Any episodes of fits? ■Drugs (alcohol, marijuana, hypotensive, psychotropics, others? General medical and surgical history. SADMA? FHx 13

14. Physical examination ■General appearance. BMI ■Vital signs: look for postural hypotension- very important, fever ■Eyes: visual acuity and nystagmus ■ENT: hearing tests and Otoscopic examination may reveal signs of inflammation associated with acute vestibulopathy, scarring of the eardrum from chronic suppurative otitis media, or an erosive cholesteatoma. ■Facial asymmetry. ■CVS: atherosclerosis: Carotid Bruit ■Cranial nerves ■Cerebellum: gait, coordination, reflexes, Romberg test, finger-nose tests ■Neck: cervical spine ■Dix-Hallpike Maneuver for BPPV 14

15. Diagnosis & Management ■This is a case of Vestibular Neuronitis. This is a temporary condition. It will disappear by itself by sometime. It will take a few days to a few weeks. Vestibular Neuronitis – is same as Bell’s palsy – same mechanism. ■The treatment is bed rest. Try to look to the opposite direction that induces vertigo. ■Medications: (also given in motion sickness). Stemetil – prochlorperazine ■Follow up in a few weeks ■No complications – injury from loss of balance. ■It is common around this age more common in females. 15

17. Case 1: You are working in a primary care facility attached to a teaching hospital and a 50-year-old man is consulting you about intense dizziness. He is a previous patient who is overweight, and he is on medications for control of hypertension and hyperlipidemia. He appears unwell and distressed with slight drooping of left eyelid. His wife drove him to the hospital. Task ■History ■Physical examination ■Diagnosis and management with examiner 17

18. History ■Is my patient hemodynamically stable? Can you describe it for me please? When you have dizzy spells, do you just feel light headed or do you see the world spinning around you?’ Since when? Duration? Is Paroxysmal or continuous? How often do you get this feeling? Is it the first time? Is it progressing? What makes it better/worse? Effect of position and change of posture? ■Did it get better or worse? Did you try to stand or walk after this? Any association with headache? 18

19. ■Nausea, vomiting-very important. Any aural symptoms such as tinnitus (ringing in your ears) or deafness or pain in the ears? Have you had any flu recently? Recent colds? I had a flu a few days ago. Any history of head injury? ■Have you noticed any asymmetry of Face? Any associated weakness (or Numbness / tingling) in your Arms or legs? Any trouble with Speech. Sight (diplopia, blurring), Swallowing? Did you lose consciousness/confusion? Change in gait? Is he able to walk? ■Chest pain? Racing of heart? SOB? Palpitations? Vomiting? Waterworks? Bowel motions? Any episodes of fits? ■General health? Previous history of stroke, cardiac problems such as heart attack, valve disease, hypertension? Diabetes? Lipid levels? ■Drugs (alcohol, marijuana, hypotensive, psychotropics, others? General medical and surgical history. SADMA? FHxDo you have enough support? 19

20. Physical examination ■General appearance and BMI ■Vital signs: especially BP (postural drop) and PR (rate and rhythm) ■HEENT: facial asymmetry, ophthalmoplegia, fundoscopy, Nystagmus positive on ipsilateral. Eye movements and pupil reactions (PEARL) are normal as is fundoscopy. Nystagmus to the left on looking to the left is present. A left Horner syndrome is present (ptosis, miosis of pupil). 20

21. Neurologic exam: ■Cranial nerves (usually II-XII, but normal in his case). Cerebellar signs positive (DANISH) on the same side as of lesion. ■Peripheral motor system, upper and lower limbs: IPTRCS. ■Sensory examination, upper and lower limbs: ■Pain sensation to pinprick is lost on the left side of the face and the direct corneal reflex is absent. Power of the muscles of mastication is normal. Vibration and joint position sense and light touch sensation are normal. Appreciation of pain and temperature sensation is reduced down the whole of the right side of the body below the face. Significance of crossed signs, particularly loss of pain sensation to left face but to opposite side of trunk and limbs. ■Lower limbs: additional examination of the gait! ■Skull and spine for local disease (neck stiffness) 21

22. ■The main findings on neurologic examination are that he has an ataxic gait and postural unsteadiness without significant change on closing eyes. He has some incoordination of movement of the left arm and hand, but no motor weakness or other motor signs are present. Hearing is normal in both ears. ■CVS especially carotid arteries (don’t palpate both at once!). I told I am going to examine the precordium, apex beat, listen to the heart and check carotid bruits. Examiner asked me to show how to look for carotid bruits. I used the bell of the stethoscope. ■BSL and Urine dipstick, ECG. 22

23. Diagnosis and Management: Acute Vertigo (PICA) Lateral Medullary Syndrome (Wallenberg Syndrome) ■Most likely the patient has PICA syndrome because of the obstruction of the blood supply to the brainstem and cerebellum. Vertigo is of central brainstem or cerebellar origin. Significance of crossed signs (numbness on ipsilateral face and contralateral body) plus cardiovascular risk factors present in the patient. ■It is a medical emergency. Immediate hospital admission and assessment by the specialist is necessary. ■Investigations that are needed to be done are MRI/CT angiography (acceptable) to confirm the diagnosis. ■Other investigations are FBE, BSL, RFTs, Lipid Profile, LFTs, ECG, Echo. 23