1. Vertigo

2. Case A 58 year old presenting to us, stating that she awoke that day feeling that the room was spinning . She Had vomited twice. She seemed anxious was unsteady in her feet and was hyperventilating. She didn’t have fever, but had a sore throat, slight difficulty swallowing, slight hoarseness and a red throat. Hallpikes test induced vertigo and nystagmus.

3. Terms Vertigo is defined as the illusory sense of movement or disorientation, indicates disorder of the labyrinth or brainstem Presyncope is defined as a sense of near faint typically due to transient hypotension Disequilibrium in the elderly is often described as nonspecific slight unsteadiness, particularly in turning and indicates poor balance and strength Lightheadedness is often associated with dysfunctional breathing or anxiety

4. Is it common? • Vertigo is a common condition in the community • A fulltime GP can see 10-20 cases/year • The diagnostic challenge is to differentiate peripheral from very uncommon but very serious central causes such as brainstem stroke

5. Main clinical features to be elicited in the presence of acute vertigo are • No history of hearing loss or tinnitus? • No headache? • Onset and duration of vertigo? • Whether it is positional or sustained?

6. Examination Nystagmus during Hallpike’s manoeuvre, eye movement normal (except horizontal nystagmus) No Horners, TMs normal, No new onset deafness, No facial weakness , dysphagia, dysphonia, must be able to walk even with unsteadiness, no limb paresis, objective ataxia or sensory loss

7. Red flags to look for on examination • Any central neurological symptoms or signs • Anew type headache • Acute deafness • Vertical nystagmus

9. A 40 year old lady presenting with, sudden onset of vertigo on turning the head, with nausea. Halpikes shows rotatory nystagmus. No headache, no vomiting, no deafness, Rhombergs negative, gait normal A 45 year old lady presenting with sustained vertigo, with unidirectional horizontal nystagmus, no hearing loss or tinnitus or neurological signs, has nausea and vomiting What is the main differential diagnosis?

10. Cerebellar stroke, of a case study of 240 patients with cerebellar stroke, 25 had vertigo as sole feature. A simple test called the ‘head thrust test’ tests the vestibuloocular reflex and is always abnormal in vestibular neuronitis. It was normal in 24/25 of the cerebellar strokes. A 25 year old man presenting with vertigo, hearing loss and tinnitus with symptoms of urti, no neurological symptoms, head thrust is positive, what is the likely diagnosis, what will you do?

11. A 80 year old man presenting with vertigo unilateral hearing loss, tinnitus, headache, facial pain and tingling, what needs to be ruled out A 50 year old presenting with vertigo, tinnitus and fluctuating hearing loss with a sensation of aural pressure