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Dizziness (Scenario B)

This clinical scenario outlines the case of a 66-year-old male with sudden onset dizziness, characterized by a spinning sensation, associated symptoms of headache, and vomiting. Key clinical findings include nystagmus, a potential indicator of vestibular pathology. Differentiating between central and peripheral causes of nystagmus is essential, considering the patient's vascular risk factors and associated neurological signs. The management plan involves symptomatic relief, investigations, and consideration of possible cerebral causes. Further actions include CT scanning and neurology consultation.

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Dizziness (Scenario B)

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  1. HKCEM College Tutorial Dizziness(Scenario B) Author Dr. TW Wongrevised by Dr. Lam Pui Kin, Rex Oct., 2013

  2. Scenario B-- M 66, DM, HT • O Today, sudden • P Spontaneous onset, no provoking factor • Q spinning sensation • R increase vertigo with turning of head/body • S can sit up but cannot walk • T for a few hours; no previous episode • Associated symptoms: headache + vomiting; no limb weakness • Exam: essentially normal except +ve for nystagmus; no neck rigidity

  3. Nystagmus? Central vs Peripheral Peripheral • Horizontal • Fixed direction • Fatigable • Disappear with fixation Central • Horizontal; vertical • Change direction with gaze • No fatigue • Fixation has no effect

  4. Nystagmus due to central causes

  5. Nystagmus due to Vestibular neuritis and Head thrust test

  6. Effect of fixation Hotson et al. Acute Vestibular Sx. NEJM 1998;339 (10)

  7. Any other features to suggest central origin? • Vascular risk factors e.g. HT, smoker • Headache, neck rigidity • Focal signs e.g. double vision • Cerebellar sign e.g. truncal ataxia < 50% pts with cerebellar infarct have nystagmus

  8. Nystagmus is horizontal and in one direction • What is your plan of action ? now… • Symptomatic relief • Investigations

  9. Investigations • Hb 12 g/dL • H’stix 10 mmol/L • ECG changes NSR, non-specific ST/T • LFT, RFT pending Patient is better but still dizzy after stemetil, what now?

  10. Patient is admitted to EM ward for further management • BP/P • Continue stemetil, panadol

  11. Progress in EM ward • Has increased headache + repeated vomiting • neck rigidity +/- • Truncal ataxia? What should one try to rule out? Your action?

  12. Stroke e.g. cerebellar should be suspected CT scan Consult Neuro PRN

  13. The end Back to Dizziness (introduction)

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