• 2 Nov, 2020
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FieldsAtrial Fibrillation / Arrythmias Benign Paroxysmal Positional Vertigo Acoustic Neuroma Cerebrovascular Accident Dehydration Postural Hypotension Meniere's Disease Migraine Labyrinthitis Vestibular Neuritis Hypoglycaemia 
Age Increases with age 40-60 Peak at 50-60 years Increases with age Increases with age Elderly Increases with age First presentation usually < 40 years Typically 30-60 years Typically 40-50 years Peak at 25-35 
Gender F > M M : F = 1 : 2 F > M M > F M = F M = F F > M M : F = 1: 2 M = F M=F F > M 
Typical Presentation A 75 year old woman with a family history of heart disease is brought into A&E after suffering from sudden onset palpitations and dizziness several times that day. Each episode resolved by itself. She has a 20 pack year smoking HX and her DH includes a beta2 antagonist A 49 year old woman visited her GP complaining of dizziness and distortion of vision when she rolled over in bed. This had been happening on and off for several days. She had no significant medical history, but suffered a viral illness 2 weeks ago. A 50 year old woman with type 2 neurofibromatosis visits her GP with a 2 month history of headaches and dizziness. On examination, she has reduced hearing in one ear. An obese 65 year old man with a history of hypertension and ischaemic heart disease is brought to A&E complaining of dizziness, nausea and confusion. On examination, he has reduced GCS and paraesthesiae A 90 year old woman who lives alone is brought into A&E with a headache, dizziness and delirium. On examination, she is hypotensive, and over 24h produces only a few mls of very dark urine. A 72 year old woman who has recently had surgery feels very light-headed and falls to the floor when she tries to get up to go to the toilet. She has a history of anaemia and takes beta blockers for her hypertension. An elderly woman visits her GP with a history of recurrent episodes of vertigo, tinnitus and hearing loss. He performs the Hallpike manoeuvre which elicits nystagmus. A 19 year old female on the contraceptive pill develops recurrent, severe headaches which are unilateral and throbbing in nature, associated with nausea, dizziness and photosensitivity An anxious 40 year old woman visits her GP with acute onset vertigo. She recently suffered from an upper respiratory tract infection but reports having made a good recovery. On examination she has nystagmus and hearing loss. A woman presents to her GP with a 2 day history of vertigo, nausea and vomiting. On examination she has nystagmus but no hearing loss. One week ago she suffered from a cold but has no other relevant PMH. A 30 year old woman with a history of poorly controlled type 1 diabetes is brought to A&E by her friend. She is anxious and feels dizzy with palpitations. On examination her pupils are dilated and she is pale and sweaty. 
Other Symptoms ● Sudden; recovery in seconds (may be continuous for prolonged periods if AF) ● Several times a day and in any posture ● Dizziness ● Palpitations ● Chest pain ● Presyncope/ syncope ● Sudden ● Associated with change of head position ● Resolves in seconds ● Dizziness ● Vertigo ● Nausea ● Insidious onset ● Unilateral hearing loss ● Vertigo ● Nausea ● Vomiting ● Tinnitus ● Acute ● Dizziness ● Acute vision loss ● Headache ● Nausea ● Subacute onset ● Headache ● Dizziness ● Delirium ● Thirst ● Paraesthesia ● Seizures ● Sudden; recovery in seconds to minutes ● When standing from sitting/lying flat ● Light-headedness ● Weakness ● Syncope ● Seizures ● Acute onset ● Recurrent attacks of vertigo lasting >20 min ● Nausea ● Vomiting ● Tinnitus ● Headache, typically unilateral and throbbing. May be absent ● GI disturbance – may be associated with N&V ● Dizziness ● Photophobia ● Aura ● Made worse by physical exertion ● Resolves through sleep ● Acute ● Resolves within days-weeks ● Illusion of movement ● Severe vertigo ● Nausea ● Vomiting ● Sub-acute (hrs-days) ● Resolves within days-weeks ● Illusion of movement ● Severe unilateral vertigo ● Nausea ● Vomiting ● Acute ● Dizziness ● Tremor ● Hunger ● Palpitations ● Seizure 
Pain Usually pain free. May have symptoms of MI if this is a contributing factor to the arrythmia N / A N / A Usually painless. If pain, suspect a different diagnosis. N / A N / A N / A ● Sub-acute - may build up over minutes or hours ● Can last hours to days ● Recurrent ● Unilateral, throbbing ● Headache not necessarily always present, especially if a history of similar episodes N / A N / A N / A 
Signs ● Hypotension ● Pulmonary oedema ● Arrhythmia ● Nystagmus on performing Hallpike manoeuvre ● Resolves on performing Epley manoeuvre (clears debris from ears) ● CN signs: ipsilateral CN V, VI, IX and X may be affected ● Later, signs of raised ICP ● Speech problems ● Focal weakness ● Confusion ● Parasthesias ● Memory loss ● Hypotension/ orthostatic hypotension ● LOC ● Decreased U/O ● Reduced skin turgor ● Dry mucous membranes ● LOC ● Distorted hearing ● Blurred vision ● Drop of systolic BP>20mmHg or of diastolic BP of >10mmHg after standing for 3mins vs. lying down. ● Fluctuating sensorineural hearing loss ● Positive result to Dix-Hallpike maneuver and/or the roll test ● Heightened sensitivity to pain ● No clinical/ neurological signs ● Prostration (bowing) ● Hearing loss ● Prostration (bowing) ● Positive Romberg’s test (fall towards affected side) ● Perspiraton ● LOC ● Pallor ● Dilated pupils ● Anxiety 
Past Medical History ● FH heart disease ● HX arrhythmias ● MI ● Coronary artery disease ● LV aneurysm ● Mitral valve disease ● Cardiomyopathy ● Pericarditis ●Myocarditis ● Aberrant conduction pathway disorder ● Recent caffeine consumption ● Smoker ● High alcohol consumption● Pneumonia ● DH Beta-2 agonists, digoxin, L-dopa, Tricyclic antidepressants, doxorubicin ● Metabolic disorder ● Phaeochromocytoma ● Recent hx fast head movement ● Stress ● Lack of sleep ● Post-head injury ● FH ● Neurofibromatosis, especially NF2 ● Atherosclerosis ● HX stroke ● Ischaemic heart disease ● Smoker ● HTN ● Hyperlipidaemia ● DM ● Pregnancy ● OCP ● Illicit drug use (cocaine) ● Dementia ● HX of fluid deprivation ● Immobility ● Renal impairment ● HX alcohol abuse ● Autonomic neuropathy ● Beta blockers ● Vasodilator medication ● Diuresis ● Multi-system atrophy ● Anaemia ● Prolonged bed rest ● Blood loss ● Dehydration ● Addison’s disease ● Heart disease ● Hypopituitarsim ● Viagra ● Tricyclic antidepressants ● MAO inhibitor ● HX recent viral illness ● HX middle ear infection ● Head trauma ● Upper respiratory tract infection ● DH Aspirin ● Smoker ● Excessive salt consumption ● Triggers include chocolate, cheese, caffeine, alcohol, travel, exercise, anxiety ● DH: OCP ● Anxiety ● Obesity ● Recent weight loss ● Patent foramen ovale ● HX viral or bacterial infection ● Head injury ● Stress ● Allergy ● Upper respiratory tract infection ● HX viral illness ● Diabetes ● HX poor control of glucose levels ● Recent illness ● HX Hypoglycaemic episodes ● Hyperinsulinaemia 
Bloods Check: ● FBC ● U&E ● Glucose ● Ca2+ ● Mg2+ ● TSH ● All normal ● None specific ● Usually all normal ● Raised Urea and creatinine (compare to old results to assess level of acute vs. chronic) ● Hyperalbuminaemia ● All normal. May help to differentiate from dehydration (where Urea and creatinine will be raised) ● All normal ● All normal ● All normal ● All normal ● Low glucose 
Imaging ● Chest x-ray (cardiomegaly, heart failure, pneumonia) ● CT/MRI if diagnostic uncertainty to demonstrate otoliths ● Contrast-enhanced CT to see neuromas >2cm diameter ● MRI with gadolinium enhancement to visualise smaller tumours ● CT ● MRI ● Diffusion-weighted MRI ● MR angiography ● All normal, however, sensible to perform a screen for infection / other cuase in any frail elderly patient with falls / confusion. This should include CXR, urinalysis and ECG as a minimum. 'Dehydration' should be more of a diagnosis of exlusion. N / A ● MRI to exclude acoustic neuroma or superior canal dehiscence N / A ● All normal ● All normal N / A 
Additional Investigations ● ECG: shows arrhythmia ● Echo to look for structural heart disease, e.g. mitral stenosis ● Provocation tests e.g. exercise ECG, cardiac catheterisation +/- electrophysical studies may be required N / A N / A N / A N / A N / A N / A N / A N / A 
Full Article Atrial FibrillationVertigoVertigoStrokePostural HypotensionVertigoMigraineVertigoVertigoDiabetes