Dizziness - the GP perspective

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Dizziness - the GP perspective

• Dr Manj Tawana
• Tuesday 27 May 2014

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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)

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Learning Objectives (SMART)

• Group.
• Individual.
• Outside scope for today? Further learning?
• Resources.
• 
  10 mins

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Group work

• Elderly patient walks into your GP consulting
  room....
• Doctor Ive been getting dizzy spells.
• 10 minute consultation with patient.
• Assessment? (history, examination, tests,
  management, ?referral).
• Differentials?
  30 mins

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Group work

• Present back....
• 
  30 mins

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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.

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Dizziness

• Vertigo
• 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.

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Dizziness

• Lightheadedness
• 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.

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Dizziness

• in addition the following conditions too may
  present with dizziness...
• psychiatric disorders
• seizure disorders
• motion sickness
• otitis media
• cerumen impaction

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Dizziness

• Multisystem failure esp. elderly patients.
• Polypharmacy
• Poor eyesight
• Cardiac problems
• Cerebrovascular disease
• BPPV
• Burnt out menieres
• Vestibular failure
• Incomplete central compensation
• Peripheral neuropathies
• Muscle weakness
• Arthritic joints

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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?

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History

• onset 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.

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History

• precipitating 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.

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History

• associated 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.

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Examination history driven

• History 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.

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Treatments...

• Consider
• Labyrinthitis Prochlorperazine.
• BPPV Epley manoeuvre, Brandt-Daroff
  exercises, prochlorperazine.
• Menieres disease Betahistine, prochlorperazine,
  ?refer.
• Acoustic neuroma Refer.
• Vert. insufficiency Modify risk factors BP,
  smoking, aspirin, statin?

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BMJ Learning Falls Quiz.

• Individually, pairs.
• Pre-test.
• Post-test.

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Finish-up, anything else?

• Learning objectives?
• Further learning?
• Resources?

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• Thank you!
• Good luck!