Dizziness

1. King Khalid University College of medicine Department of family & community medicine Dizziness Prepared by : -Abdurrahman Al qahtani - Abdullah Alammar - Khalid Aldossari - Abdullah Alshehri - Fahd Alshehri -MazenAlshahrani -Ali Almater Supervised by : Prof. Khalid S. Al-Gelban

2. Clinical scenario . • Mona Mohd. , a 43 old woman, she is housewife came to PHCC with chief complaint … Mona : dr. I sometimes felt dizzy in the last 2 months DR. : When you have dizzy spells, did you feel light-headed or do you see the world spin around you ? Mona : I feel the world spin over around me . DR : tell me about onset, frequency& severity .. Mona : well doctor, it started gradually before 2 months , and I feel dizzy 1 to 2 times a day , and it is not so severe .

3. DR: is it associated with any sort of deafness ? Mona : only a little pit I feel that in my Rt. Ear . • DR; any ear discharge or feeling fullness in the ear ? Mona : No • Any migraine headache ? Mona : No • DR :for how long this dizzy reaming ? Mona : 2-3 hours . • DR : any aggravating or relieving factor ? Mona : yes , aggravated by head movement and Relieved by bed rest . • DR : tell me about the associated complaints ? Mona : sometimes .. Nausea and vomiting ? • DR : is it associated with tinnitus or headache ? Mona : yes , tinnitus in my Rt. Ear , and no headache .

4. Any recent upper respiratory infection or fever ? • Mona : No . • Any head or ear trauma ? • Mona : no • Any sleep disturbance , loss of appetite , loss of interest ? • Mona : No .

5. Any previous angina , MI ? • Mona : No • Are you HTN , D.M. , smoker ? • Mona : No • Any medicine you use ? • Mona : Sometimes Paracetamol . • Any similar condition in your family ? • Yes , my father complain from the same problem before one year , and now he is O.K.

7. Objectives • Definition . • Epidemiology . • Classification ( according to patient history ) . • Causes . • DDx. • Hx. • Physical examination . • Investigations • Management • Referral .

8. Objectives • Definition . • Epidemiology . • Classification ( according to patient history ) . • Causes . • DDx. • Hx. • Physical examination . • Investigations • Management • Referral .

9. Dizziness is defined as perception or sensation of oneself or one`s environment is moving or room spinning . It also refers to sensation of lightheadedness or faintness to spinning or a feeling of imbalance .

10. Objectives • Definition . • Epidemiology . • Classification ( according to patient history ) . • Causes . • DDx. • Hx. • Physical examination . • Investigations • Management • Referral .

12. Dizziness is common in : • Elderly . • Middle aged . • Females . • Psychiatric patients . • Patients on drugs . • Patients suffering from chronic diseases such diabetes and hypertension.

14. Objectives • Definition . • Epidemiology . • Classification ( according to patient history ) . • Causes . • DDx. • Hx. • Physical examination . • Investigations • Management • Referral .

15. 1- vertigo : The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis . 2- disequilibrium : Parkinson diseaseand diabetic neuropathy should be considered with the diagnosis of disequilibrium 3- presyncope: Many medications can cause presyncope, and regimens should be assessed in patients with this type of dizziness . 4- lightheadedness : Psychiatric disorders, such as depression, anxiety, and hyperventilation syndrome, can cause vague lightheadedness

17. Cont..

18. Cont..

19. Otologic or vestibular causes of vertigo are the most common causes of dizziness, and include benign paroxysmal positional vertigo (BPPV), vestibular neuritis (viral infection of the vestibular nerve), labyrinthitis (infection of the labyrinthine organs), and Meniere disease (increased endolymphatic fluid in the inner ear). • An estimated 35 percent of adults 40 years and older have vestibular dysfunction. • Vertigo with hearing loss is usually caused by Meniere disease or labyrinthitis, whereas vertigo without hearing loss is more likely caused by BPPV or vestibular neuritis

20. Episodic vertigo tends to be caused by BPPV or Meniere disease, whereas persistent vertigo can be caused by vestibular neuritis or labyrinthitis . Vertigo Central Peripheral

21. Central Peripheral Associated with hearing loss and tinnitus. Mostly due to 8th cranial nerve etiology. Causes : - Benign Paroxysmal Positional Vertigo BPPV - Acoustic neuroma - Labyrinthitis - Menier’s disease - Perilymph fistula No hearing loss No tinitus Causes : - cerbrovascular causes - MS . - Drugs (Vertebro-basillar insufficiency: severe vertigo hiccoughs dysphagia Dx: MRI )

22. ONLY symptom is: VERTIGO. No hearing loss, No tinnitus. Comes when patient is getting up. Mostly due to otoliths‘ear stones’. Dx:  Dix-Hallpiketest Rx: Positional maneuvers to dislodge the otoliths.

23. The Epley maneuver. This maneuver is used to treat benign positional vertigo by returning displaced otoliths to the utricle. If vertigo occurs during any of the positions, that position is held until the vertigo subsides.

24. Shwanoma of the 8th cranial nerve. Not related to patient’s position. Unilateral hearing loss Unilateral Tinnitus. ATAXIA. Dx: CT, MRI Rx: Surgery

25. Not related to patient’s position. Hearing loss. Tinnitus. SINGLE episode. Recent VIRAL illness. Rx: self limited.

26. Over-production of endolymph. Not related to patient’s position. Hearing loss. Tinnitus. MULTIPLE RECURRENT episodes. Rx: Low salt diet. Diuretics. Surgery.

27. Not related to patient’s position. Hearing loss. Tinnitus. Hx. of TRAUMA. Rx: Resolves spontaneously. Surgical repair.

28. ,, is another underlying cause of vertigo that affects about 3 percent of the general population and about 10 percent of persons with migraine • Diagnosis of migrainous vertigo is established in patients with a history of episodic vertigo with a current migraine or history of migraine and one of the following symptoms during at least two episodes of vertigo: migraine headache, photophobia, phonophobia, or aura.

29. Cardiovascular causes of dizziness include arrhythmias, myocardial infarction, carotid artery stenosis, and ortho-static hypotension. Of patients with supraventricular tachycardia, 75 percent experience dizziness and about 30 percent experience syncope. • Symptoms brought on by postural changes suggest a diagnosis of orthostatic hypotension.

30. Cardiac syncope MI: ECG & cardiac enzymes. Aortic stenosis: Echocariography. Arrhythmia: ECG .

31. There are many underlying conditions that may cause a sense of imbalance. Stroke is an important and life-threatening cause of dizziness that needs to be ruled out when the dizziness is associated with other symptoms of stroke. However, other neurologic findings are generally present. • In a population-based study of more than 1,600 patients, 3.2 percent of those presenting to an emergency department with dizziness were diagnosed with a stroke or transient ischemic attack (TIA), but only 0.7 percent presenting with isolated dizziness were diagnosed with stroke or TIA.

32. Poor vision commonly accompanies a feeling of imbalance, leading to falls. The physician should inquire about a history of other problems that may cause imbalance, such as Parkinson disease, peripheral neuropathy, and any musculoskeletal disorders that may affect gait. • Use of benzodiazepines and tricyclic antidepressants increase the risk of ataxia and falls in older persons.

33. Psychiatric causes of lightheadedness are common, particularly anxiety; therefore, questions about anxiety and depression should be included in the patient history. • In one study, about 28 percent of patients with dizziness reported symptoms of at least one anxiety disorder. • In another study, one in four patients with dizziness met criteria for panic disorder. • Up to 60 percent of patients with chronic subjective dizziness have been reported to have an anxiety disorder. • Depression and alcohol intoxication have also been found to overlap with dizziness.

34. Hyperventilation syndrome is an important cause of lightheadedness. Although the condition can be associated with anxiety disorders, many patients without anxiety experience hyperventilation. • Hyperventilation is defined as breathing in excess of metabolic requirements, causing a respiratory alkalosis and lightheadedness. Patients may sigh repeatedly and may have associated symptoms, such as chest pain, paraesthesias, bloating, and epigastric pain.

35. Objectives • Definition . • Epidemiology . • Classification ( according to patient history ) . • Causes . • DDx. • Hx. • Physical examination . • Investigations • Management • Referral .

37. Differential Diagnosis Acute life threatening : a. Cerebral hemorrhage (stroke). b. Myocardial infarction . c. Cardiac arrhythmia . Infectious : a. Acute neurolabyrinthitis. b. Acute vestibular neuritis. c. Neuro-syphilis.

38. Serious: a. Brain tumors b. Drug overdose c. Severe depression. d. Aortic stenosis. e.Acousticneuroma Metabolic: a. Hyperglycemia. b. hypoglycemia. c. hypothyroidism

39. Psychiatric: a. depression. b. Anxiety c. Stress d. Panic attacks Ear causes: a. Benign positional vertigo b. otitis media c. Acute labyrinthitis d. meniere`s disease e. Acoustic neuroma. f. peri-lymphatic fistula .

40. Central nervous system : a. stroke. b. Multiple sclerosis. c. Brain tumors. d. migraine. e. epilepsy.

41. Objectives • Definition . • Epidemiology . • Classification ( according to patient history ) . • Causes . • DDx. • Hx. • Physical examination . • Investigations • Management • Referral .

43. Identify • patient’s name • Age • Job • Marital status

44. Explore chief complaint

45. Clarify the complaint • Is it true vertigo? • Is it light headedness? • Is it pre-syncope? • Is it disequilibrium? Ask the patient , describe your feelings !? Vertigo: The patient feels perception or sensation of himself or his environment is moving or room is spinning (False sense of motion, possibly spinning sensation) . Light headedness: It is a vague floating sensation (feeling disconnected with the environment ) Pre-syncope: Feeling of an impending fainting but no loss of consciousness. Disequilibrium: An ability to keep balance usually associated with unsteady gait.

46. Duration ? (second, minutes, hours, days) • Frequency ? (acute, recurrent, chronic) • Intensity ? (mild, moderate, severe) • Aggravating factors ? (sitting, standing, rolling over, bending over) • Relieving factors ? (sitting, standing, rolling over)

47. Ask about the associated symptoms .. • Neurological symptoms: • Headache (migraine) ? • Numbness, tingling ? • Blurring of vision ? • Body weakness ? • Par aesthesia ?

48. Ear symptoms: • Hearing loss (Deafness) ? • Tinnitus ? • Ear pain ? • Ear discharge ?

49. Head & Neck: • Neck pain ? • Head trauma ?

50. Cardiovascular & Pulmonary symptoms: • Chest pain ? • Palpitation ? • Dyspnea ? • Chronic cough ?