Dizziness

Diagnoses

100

What are common peripheral causes of dizziness and vertigo.

What are: -Vestibular neuritis -Otosclerosis -Benign paroxysmal positional vertigo -Meniere disease

200

Name two common central causes of vertigo and dizziness.

What are: -Meningiomas involving the cerebellopontine angle and posterior fossa -Cerebrovascular disease -Vestibular migraines

300

Identify two additional causes of vertigo and dizziness apart from those listed in previous questions above.

What are: -Medication induced: nitrates, PDE-5 inhibitors, antiparkinsonian agents and many more. See list -Psychiatric causes: episodic and then often becoming chronic and associated with anxiety, depression and bipolar disorder. -Orthostatic (very common particularly in elders) -Cardiovascular and metabolic: arrhythmias and endocrine disorders such as Addison's disease of diabetes insipidus. Anemia is another common cause.

400

This condition is present when the systolic blood pressure decreases 20 mm Hg, the diastolic blood pressure decreases 10 mm Hg, or the pulse increases 30 beats per minute after going from supine to standing for one minute.

What is orthostatic hypotension Treatment?

500

This test helps to assess position sense. Have the patient stand with both feet together, and then note whether the patient can maintain balance after closing his or her eyes.

What is Romberg test. -Patients with an unsteady gait should be assessed for peripheral neuropathy. A positive Romberg test suggests an abnormality with proprioception receptors or their pathway.

Algorithm

100

First question asked in dizziness algorithm.

Is dizziness episodic or persistent

Labs/imaging/demographics

100

List standard cardiac oriented tests to evaluate for dizziness.

What are: -ECG -Event monitor -Consider carotid U/S

200

Chronic metabolic disease testing in dizziness should at baseline include the following common tests.

What is BMP: checking glucose and electrolytes

300

What are the indications for imaging in dizziness.

As a general rule (we know general rules are problematic in medicine) routine imaging is not indicated. -A CT or MR is indicated if there are any abnormal neurologic findings including asymmetric or unilateral hearing loss. Want to exclude mass and cerebrovascular disease. N.B. hearing loss with vertigo and normal imaging suggests Meniere disease.

400

Among which age group is BPPV most common

What are 50 to 70 year olds No cause is found in 50% to 70% of patients and head trauma is a more common etiology in younger patients.

500

Vertigo is an initial symptom in 48% of people with this morbid condition.

What is vertebrobasilar ischemia

Evidence Based Recs

100

Vertigo associated with unilateral hearing loss is characteristic of this disease.

What is Meniere Disease AAFP SORT: level C (consensus, expert opinion or case series)

200

Treated effectively with canalith repositioning maneuvers such as the Epley.

What is benign paroxysmal positional vertigo SORT: Level A (good quality evidence)

300

The second most common cause of vertigo can be treated with medications (antiemetics and antihistamines) and vestibular rehabilitation therapy ( a form of physical therapy that uses specialized exercises that result in gaze and gait stabilization) Most VRT exercises involve head movement since head movements are essential in stimulating and retraining the vestibular system when treating this condition.

What is Vestibular Neuritis SORT: C (expert opinion)

400

This pneumonic can be used to differentiate a peripheral cause of vestibular neuritis from a central cause.

What is the HINTS examination. The HINTS (head-impulse, nystagmus, test of skew) examination can help differentiate a peripheral cause of vestibular neuritis from a central cause. SORT: level C

500

This condition may improve with a low salt diet and diuretic use.

What is Meniere Disease. First-line treatment of Meniere disease involves lifestyle changes, including limiting dietary salt intake to less than 2,000 mg per day, reducing caffeine intake, and limiting alcohol to one drink per day. Daily thiazide diuretic therapy can be added if vertigo is not controlled with lifestyle changes. SORT: level B

Medications

100

Name two antiemetics that are used as vestibular suppressant medications.

What are metoclopramide (Reglan) and prochlorperazine Both are dopamine receptor antagonists

200

Name two antihistamine agents used as vestibular suppressant agents.

What are: meclizine, dimenhydrinate and promethazine. All are first generation histamine blockers.

300

List two benzodiazepines used occasionally as vestibular suppressant medications.

What are diazepam and lorazepam. Bind to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron at several sites within the central nervous system. Enhancement of the inhibitory effect of GABA on neuronal excitability results by increased neuronal membrane permeability to chloride ions. This shift in chloride ions results in hyperpolarization (a less excitable state) and stabilization.

400

Name two classes of commonly used meds that are centrally acting anticholinergic agents.

What are: -Skeletal muscle relaxants:cyclobenzaprine (class related to TCAs) -Urinary and GI antispasmodics: oxybutynin and dicyclomine as respective examples.

500

This class of antidiabetic agents may cause dizziness due to a glucosuric effect.

What are the Sodium–glucose cotransporter-2 inhibitors. SGLT-2 inhibitors such as Canagliflozin.