Dr Manj TawanaTuesday 27 May 2014

This afternoon:This afternoon:Introductions (1.30 – 1.40pm)

Learning objectives (1.40 – 1.50pm)

Small group work and re-convene (1.50 – 2.50pm)

Break (2.50 – 3.10pm)

Presentation (3.10 – 3.30pm)

Quick quiz, finish-up, anything else? (3.30 – 4.00pm)

Learning Objectives (SMART):Group.

Individual.

Outside scope for today? Further learning?

Resources.

10 mins

Group work:Elderly patient walks into your GP consulting room....

“Doctor I’ve been getting dizzy spells.”

10 minute consultation with patient.

Assessment? (history, examination, tests, management, ?referral).

Differentials? 30 mins

Group work:

Present back....

30 mins

Dizziness

Non-specific term: sensation of altered orientation in space.

Vertigo: hallucination of rotation or movement of one's self or one's surroundings.

Dizziness is of little diagnostic value without trying to elaborate further information.

If there is loss of consciousness then this defines the term syncope.

Suggested that there are four types of dizziness.

DizzinessVertigo

commonest type – more than 50% of cases of dizziness in primary care.

may be described as an illusion of movement (i.e., a false sense of motion).

it is frequently horizontal and rotatory. illusion of rotation may be of one's self or one's

surroundings may be associated with nausea, emesis, and diaphoresis. cause may be central or peripheral.

when associated with nausea and vomiting, should look for a peripheral rather than central cause

most cases can be diagnosed clinically and managed in the primary care setting.

DizzinessLightheadedness

this is non-specific. sometimes difficult to diagnose . may be associated with panic attacks.

Presyncope is due to cardiovascular conditions that reduce

cerebral blood flow.

Dysequilibrium feeling of unsteadiness and instability. causes include: peripheral neuropathy, eye disease,

peripheral vestibular disorders.

Dizzinessin addition the following conditions too may

present with dizziness...

psychiatric disordersseizure disordersmotion sicknessotitis mediacerumen impaction

Dizziness

Multisystem failure – esp. elderly patients.PolypharmacyPoor eyesightCardiac problemsCerebrovascular diseaseBPPVBurnt out meniere’sVestibular failureIncomplete central compensationPeripheral neuropathiesMuscle weaknessArthritic joints

History – essential! Vertigo

do you get the feeling of rotation? do the surroundings spin around? is there a tendency to fall to one side?

Dysequilibrium are you having a feeling of unsteadiness?

Presyncope do you feel faintish?

Lightheadedness do you feel lightheaded?

Historyonset and duration of the symptoms:

Few seconds: peripheral causes: unilateral loss of vestibular function,

acute vestibular neuronitis, Meniere's disease. Several seconds to a few minutes:

BPPV. Several minutes to one hour:

TIA. Several hours:

Meniere's disease, migraine, acoustic neuroma. Days:

early acute vestibular neuronitis, CVA, migraine, MS.

Historyprecipitating factors:

spontaneous episodes acute vestibular neuronitis, cerebrovascular

disease, Meniere's disease, migraine, MS.

changes in position of the head acute labyrinthitis, BPPV, cerebellopontine angle

tumour, MS.

standing up postural hypotension.

Historyassociated symptoms, including:

deafness. tinnitus. otalgia . a feeling of fullness in the ear. discharge from the ear. neurological symptoms.

any other medical problems: vascular disease. MS. drug history, esp. ototoxic drugs. cardiac disease, esp. arrhythmias.

Examination – history drivenHistory driven, may be normal at time of seeing

patient!

Neurological: CNs, cerebellar (finger-nose) , Dix-Hallpike.

Head and neck: carotids (neck bruits), arthritic C-spine (abnormal proprioceptive signals), TMs.

Cardiovascular system: pulse, BP, carotids, arrhythmias.

Treatments...Consider:

Labyrinthitis: Prochlorperazine.BPPV: Epley manoeuvre,

Brandt-Daroff exercises, prochlorperazine.

Meniere’s disease: Betahistine, prochlorperazine, ?refer.

Acoustic neuroma: Refer.Vert. insufficiency: Modify risk factors – BP,

smoking, aspirin, statin?

BMJ Learning – Falls Quiz.

Individually, pairs.

Pre-test.

Post-test.

Finish-up, anything else?

Learning objectives?

Further learning?

Resources?

Thank you!

Good luck!