13 Questions
What is the primary reason for the feeling of disequilibrium in vertigo?
An alarm warning from the cortex
Which type of vertigo is characterized by severe disequilibrium with less spinning but neurological deficit?
Central vertigo
What is the term for the classification of vertigo based on the timing of the attacks?
Paroxysmal, acute, or chronic
Which of the following is NOT a cause of peripheral vertigo?
Ramsay Hunt Syndrome
What is the primary difference between central and peripheral vertigo?
The location of the affected area in the brain
What is the primary goal of the Dix-Hallpike and head shake tests?
To differentiate between peripheral and central lesions
What is the characteristic of the fast phase of nystagmus?
It is a corrective phase
What is the primary purpose of the Romberg test?
To evaluate the patient's balance and posture
What is the characteristic of peripheral vestibulopathy in the vestibuloocular reflex test?
It shows a corrective saccadic eye movement to the site of the lesion
What is the primary cause of reduced cardiac output (CO) in cardiac pathophysiology?
All of the above
What is the primary goal of primary prevention of sudden cardiac death (SCD)?
To identify patients at high risk of SCD
What is the main purpose of the implantable loop recorder in the diagnosis of SCD?
To monitor the patient's heart rate and rhythm over a long period of time
What is the characteristic of inherited arrhythmogenic disease in the context of SCD?
It is always associated with a family history of SCD
Study Notes
Vertigo
- Normal coordination between vestibular system, vision, and proprioception is essential for maintaining balance and equilibrium.
- Discord in information, abnormal or excessive stimuli, or failure in coordination can lead to vertigo.
- The feeling of disequilibrium in vertigo is an alarm warning from the cortex.
Types of Vertigo
- Central vertigo: affects the brain, characterized by severe disequilibrium with less spinning, neurological deficit, and unprovoked and prolonged attacks.
- Peripheral vertigo: affects the balance apparatus, characterized by mild disease, spinning, and hearing dysfunctions.
Causes of Peripheral Vertigo
- Canalithiasis (BPPV)
- Meniere's disease
- VZV leading to Ramsay Hunt Syndrome
- Labyrinthitis
- Otosclerosis
- Cholastoma
Considerations for Vertigo Classification
- Vestibular or non-vestibular?
- Peripheral or central?
- Timing: paroxysmal, acute, chronic?
- Provoked or spontaneous?
- Other symptoms?
- Specific physical examination: nystagmus, Dix-Hallpike, and head shake
Nystagmus
- Spontaneous nystagmus: patient is asked to focus on the examiner's finger, then moved horizontally, vertically, and rotating.
- Horizontal and rotation nystagmus tend to show peripheral vertigo.
- Pure vertical or pure rotational nystagmus shows central vertigo.
- The slow phase of nystagmus is in the direction of the lesion.
- The fast corrective phase shows the direction of nystagmus.
Other Diagnostic Tests
- Vestibulospinal tests: past pointing, Romberg, and tandem gait.
- Vestibuloocular tests: head thrust, test of skew.
- Cerebellar tests: finger 2 nose, finger 2 finger, dysdiadochokinesia, rebound test.
- Tinnitus or deafness: Rinne, Weber.
Cardiac Pathophysiology
- Reduced cardiac output (CO) due to reduced stroke volume (SV) or heart rate (HR).
- High HR is still bad for CO due to reduced afterload.
- Increased peripheral resistance leads to inadequate blood flow to the cerebral cortex.
- Reduced blood flow to the cerebral cortex for 6-8 seconds → transient loss of consciousness (LOC).
- 50-60 systolic mmHg at heart level → syncope.
- Sudden cardiac death: unpredictable cardiac arrest, often with normal heart beats before the arrest.
Treatment of Cardiac Conditions
- Primary prevention: establish cardiovascular disease and risks, family history of SCD, previous history of SCD, syncope, arrhythmias.
- Goal is to prevent worsening, prevent triggering, and commit improvement.
- Secondary prevention: interventions for survivors of SCD, including implantable cardioverter defibrillation, acute cardiac ischaemia, heart failure, and inherited arrhythmogenic disease.
Diagnosis of Cardiac Conditions
- ECG: main goal is to exclude arrhythmia.
- Holter monitor: to see the EKG during syncope.
- Implantable loop recorder: implanted heart monitoring device that works for 3 years, used for recurrent syncopes.
- Tilt-table testing: for suspect of vasovagal syncope and orthostatic hypertension.
This quiz covers the diagnosis of nystagmus in a physical examination, including spontaneous nystagmus testing, patient positioning, and interpreting the results. Learn how to identify peripheral and central vertigo and understand the significance of the slow and fast phases of nystagmus.
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