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Royal United Hospital Bath

adamdaniel
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Royal United Hospital Bath

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    2. Today-bit of a fast ride!! How to take a proper history Principles behind history taking Identify and manage three main causes of dizziness Start to enjoy seeing dizzy patients

    3. Assumptions already identified and excluded cardiac (e.g.arrythmias) and neurological (e.g.Parkinson’s) causes of dizziness dizziness is not one of your main areas of clinical interests-you want a simple guide a consultation time of about 10-15 minutes you understand when I am a bit dogmatic today

    4. Key point Patients who give a description of rotatory dizziness, do NOT have brain tumours well very, very rarely

    5. Key point Or ear pathology well very, very rarely

    6. Diagnosis Almost always made from the history examination and investigations rarely add to the diagnosis

    7. Taking a history Ladder of interpretation Patient experience Turn it into language Patient’s medical diagnosis Doctor’s diagnosis Specialist’s diagnosis

    8. Taking a history Go back to raw data the structured interview warn the patient you may interrupt, question, push them for precise information

    9. Key point take a detailed history of one single actual (not a ‘general’) episode, avoiding the use of the word “dizzy” obtain a description in everyday language duration of this episode; secs, mins, hours information on frequency of other episodes take 5-10 minutes over this THEN MAKE A WORKING DIAGNOSIS

    10. Examination Cranial nerves 3 to 12 5 corneal reflexes 7 facial movement 8 audiogram 9,12 sensation soft palate; tongue movements 10 sharp cough and sing high note properly 11 normal sterno-cleido-mastoid function 3,4,&6 eye movements visual pursuit-smooth non saccadic tracking horizontal Vertical

    11. Hallpike-Dix test

    12. Hallpike-Dix test

    13. Hallpike-Dix test

    14. Investigations Audiological tests Vestibular tests ? Haematological tests ???? CT & MRI

    15. 4 main diagnoses “psychogenic” 30% benign positional vertigo 20% Meniere’s disease 10% multi-system ‘failure’ ??% the undiagnosed

    16. Dizziness: age and sex

    17. “psychogenic” dizziness

    18. “psychogenic” dizziness multiple short lived episodes- ‘seconds’ ‘swimming’ or ‘being on a boat’ quality can disguise this symptom from others normal physical examination feeling reproduced by hyperventilation Tx explanation, support, increased activity

    19. Dizziness and compensation mechanisms

    20. Dizziness and compensation mechanisms

    21. Benign positional vertigo

    22. Benign positional vertigo rotatory vertigo lasting @20 seconds associated with particular head position occurs in clusters lasting 7 to 14 days may be a previous history of significant head or ‘whiplash’ injury may be a positive Hallpike-Dix test Tx Epley’s repositioning; fatiguing; avoiding position

    23. Epley’s manoevre for BPV Head to side triggering BPV head straight back head to opposite side looking towards floor sitting up with head down all for 30 seconds; first thing in the morning

    24. Multi-system ‘failure’ > 70 years no sense of rotation; uncertainty of balance ‘all the time’ may be a blend of reduced visual, vestibular, proprioceptive and inadequate muscular function. Tx Increased movement n.b. no drugs

    25. Undiagnosed

    26. Undiagnosed: outcome psychogenic Meniere’s benign positional vertigo “Vestibular”Meniere’s acoustic neuroma

    27. Key point All causes of dizziness are made better by movement

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