Vertigo

Question 1

Elizabeth Finn is a 60-year-old lady with a two month history of dizziness. She states “Doctor, whenever I get up from lying down I feel like everything is spinning.”

Impression/Dx/Goals

Answer 1

Impression:

• Likely a presentation of vertigo. Important to differentiate peripheral from central vertigo. Important to rule out red flag diagnosis
• Stroke
• SOL

DDx:
Peripheral
- BPPV
- Labrynthitis (hearing loss) 
- Menieres
- Vestibular neuronitis (no hearing loss) 
- Cardiogenic:
Postural hypotension
- Vasovagal

Goals/priorities of management:

• Identify underlying aetiology
• Rule out red flag ddx, differentiate central from peripheral causes
• Implement appropriate treatment and management

Question 2

Vertigo - History

Answer 2

History:

• Sx: nature of dizziness, timing, exacerbating/relieving, distinguish cardiogenic from neurogenic, and peripheral from central, stroke sx (FAST)
• Associated symptoms - hearing loss, tinnitus, viral illness, sx of malignancy
• PMHx:
• Medications
• SNAP

Question 3

Vertigo - Examination

Answer 3

Exam:
- HINTS: rule out central cause
Head impulse: if visual saccade = peripheral
Nystagmus: if unidirectional then peripheral, if vertical/torsional then central
Test of skew: if vertical skew present = central cause of vertigo
- Dix Hallpike manoeuvre: if more likely to be BPPV → then Epley manoeuvre if positive
- Assessment of gait
- BP - Postural drop

Question 4

Vertigo - Investigations

Answer 4

Investigations:

• None usually required
• If concerned about central causes → stroke workup

Question 5

Vertigo - Management

Answer 5

Management:
Non-pharm
- Manoeuvres - epley
- Refer to physio for further patient education and treatment
- Educate the patient that BPPV usually lasts a few days then will resolve, may recur

Pharm
- Supportive → antiemetics (prochlormazepine [stemetil])
If debilitating symptoms
- Prednisolone → for labyrinthitis with hearing loss
- Menieres: Diamox (acetazolamide) - reduce inner-ear fluid, antiemetics

Safety-netting/review

• To present to ED if onset of FAST symptoms
• To re-present if non-resolving/improving with treatment manoeuvres.