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Dizziness - the GP perspective

Dizziness - the GP perspective. Dr Manj Tawana Tuesday 27 May 2014. 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)

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Dizziness - the GP perspective

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  1. Dizziness - the GP perspective Dr Manj Tawana Tuesday 27 May 2014

  2. 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)

  3. Learning Objectives (SMART): • Group. • Individual. • Outside scope for today? Further learning? • Resources. 10 mins

  4. 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

  5. Group work: • Present back.... 30 mins

  6. 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.

  7. 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.

  8. 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.

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

  10. Dizziness Multisystem failure – esp. elderly patients. Polypharmacy Poor eyesight Cardiac problems Cerebrovascular disease BPPV Burnt out meniere’s Vestibular failure Incomplete central compensation Peripheral neuropathies Muscle weakness Arthritic joints

  11. 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?

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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?

  17. BMJ Learning – Falls Quiz. • Individually, pairs. • Pre-test. • Post-test.

  18. Finish-up, anything else? • Learning objectives? • Further learning? • Resources?

  19. Thank you! • Good luck!

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