🤔 MEDIUM

Everybody now! “You spin me right round, like a record baby!”. Have a go at this quiz on dizziness and vertigo, some are more challenging! As always, read that question stem carefully!

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Approach to the patient with Dizziness and Vertigo

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Question 1

Stem 1, question 1 of 6

Claudia, a 32 year old female, presents to her GP complaining of vertigo
Which of the following is NOT a cause of vertigo?
A
Vestibular neuronitis
B
Meniere's disease
C
Alcohol related cerebellar degeneration
D
Acoustic neuroma
E
Vasovagal attack
Question 1 Explanation: 
It is important to understand that vertigo and dizziness are not synonymous. Vertigo is an illusory sensation of motion that is usually spinning or rotatory and is much more than dizziness. Vasovagal attack is the only answer option that results in dizziness rather than vertigo. All other choices are differentials for vertigo
Question 2

Stem 1, question 2 of 6

Claudia states she also has mild hearing loss in her left ear, nausea, vomiting and coryzal symptoms. She denies any otorrhoea.
What is the most likely cause of her vertigo?
A
Benign paroxysmal positional vertigo
B
Meniere's Disease
C
Bacterial vestibular neuronitis
D
Viral vestibular neuronitis
E
Labyrinthitis
Question 2 Explanation: 
This is a little harder but there are a number of clues in the stem to help you. This is describing labyrinthitis and is often caused by a viral infection. Viral vestibular neuronitis, which is an acute peripheral vestibulopathy, presents in a similar way but without the hearing loss. Otorrhoea could have indicated a bacterial infection.
Question 3

Stem 1, question 3 of 6

Claudia is given a vestibular suppressant, anti-emetic and corticosteroids.
Which of the following is a vestibular suppressant?
A
Metoclopramide
B
Naproxen
C
Tranexamic acid
D
Diazepam
E
Vancomycin
Question 3 Explanation: 
Oh pharmacology, either love it or hate it! Let's go through all the options: Metoclopramide is an anti-emetic but isn't a vestibular suppressant. Naproxen is a non-steroid anti-inflammatory, tranexamic acid is an anti-fibrinolytic so prevents the breakdown of blood clots and vancomycin is an antibiotic. That leaves us with diazepam, aka a vestibular suppressant!
Question 4

Stem 1, question 4 of 6

20 years later Claudia returns to GP with severe episodes of vertigo which started following a fall in the garden a week ago where she bumped her head. She states the vertigo is only comes on when looking over her right shoulder.
What is the most likely diagnosis?
A
Vestibular neuronitis
B
Labrinythitis
C
Meniere's Disease
D
Acoustic neuroma
E
Benign Paroxysmal Positional Vertigo (BPPV)
Question 4 Explanation: 
Hopefully this question makes more sense and straightforwards. This is a classical presentation of BPPV, which is one of the most common causes of vertigo. BPPV presents with specific provoking positions giving rise to brief episodes of severe vertigo in the absence of any neurological or ontological symptoms. Meniere's Disease presents with vertigo, low frequency hearing loss and tinnitus. Acoustic neuroma is a benign slow growing tumour that is progressive.
Question 5

Stem 1, question 5 of 6

What is the most likely examination finding in BPPV?
A
Negative Dix-Hallpile
B
Positive erect lateral head turn
C
Positive Epley manoeuvre
D
Positive Dix-Hallpike
E
Negative Epley manoeuvre
Question 5 Explanation: 
BPPV is diagnosed on the basis of two tests: Dix-Hallpike and supine lateral head turns. A positive result of either test suggests BPPV, thus the only answer choice that fits is positive Dix-Hallpike. The Epley manoeuvre is used to help more the free-floating endolymph canlith particles back to the rightful position and stop the BPPV.
Question 6

Stem 1, question 6 of 6

The GP sees another patient also complaining of vertigo, accompanied by right sided facial numbness, hearing loss and tinnitus
Where is the lesion?
A
Peripheral Vestibulocochlear nerve
B
Cerebellopontine angle
C
Nucleus ambiguus
D
Cerebral peduncle
E
Basiliar pons
Question 6 Explanation: 
This is a harder question so don't worry if you find this challenging. The stem is describing the presentation of an acoustic neuroma (vestibular schwannoma) which is a benign and slow growing tumour that grows from the cerebellopontine angle on the brainstem. The nucleus ambiguus is gives rise motor fibres of CN X, the cerebral peduncle attach the cerebrum to the brainstem, the basilar pons makes up two thirds of the pons.
Question 7

Stem 2, question 1 of 4

Paul, a 74 year old man, presents to his GP following an episode of dizziness. His husband states Paul lost consciousness momentarily and was slumped.
What is the most likely cause of Paul's dizziness?
 
A
Orthostatic hypotension
B
Bradyarrthymia
C
Partial seizure
D
Vasovagal attack
E
Hyperventilation
Question 7 Explanation: 
Common things are common! Paul is presenting with a vasovagal attack aka a faint! This is a sudden, temporary and self-terminating loss of consciousness, associated with the inability to maintain postural tone with a rapid and spontaneous recovery, resulting from a temporary inadequacy of cerebral nutrient flow. All of the other options can result in dizziness but don't quite fit the clinical presentation.
Question 8

Stem 2, question 2 of 4

Orthostatic hypotension is another cause of dizziness. What is orthostatic hypotension?
A
Fall in diastolic blood pressure of at least 30mmHg within 2 minutes of standing
B
Fall in systolic blood pressure of at least 20mmHg and/or a fall in diastolic blood pressure of at least 10mmHg within 3 minutes of standing
C
Fall in diastolic blood pressure of at least 15mmHg within 3 minutes of standing
D
Fall in systolic blood pressure of at least 20mmHg within 4 minutes of standing
E
Fall in systolic blood pressure of at least 30mmHg and/or a fall in diastolic blood pressure of at least 10mmHg within 3 minutes of standing
Question 8 Explanation: 
Orthostatic hypotension is defined as a "Fall in systolic blood pressure of at least 20mmHg and/or a fall in diastolic blood pressure of at least 10mmHg within 3 minutes of standing ". Simply put, an individual's blood pressure drops when they stand, often causing dizziness, syncope and falls. This can be exacerbated by anti-hypertensives and so care should be taken with individuals on anticoagulants and antihypertensives due to the risk of intracerebral haemorrhage.
Question 9

Stem 2, question 3 of 4

Which of the following is NOT an appropriate initial investigation for someone presenting with dizziness?
A
Blood glucose
B
ECG
C
Urea and Electrolytes
D
Full blood count
E
Aminoglycoside levels
Question 9 Explanation: 
This tests your understanding of investigations for dizziness. Blood glucose, ECG, urea and electrolytes and full blood counts are all appropriate investigations for someone presenting with dizziness. Aminoglycoside levels are important in vertigo and hearing loss as this can indicate ototoxicity but is not an initial investigation for dizziness.
Question 10

Stem 2, question 4 of 4

2 months later, Paul's husband calls the GP surgery saying that Paul has vertigo, double vision, hearing loss, difficulties speaking and numbness down his right side
What investigation does Paul require immediately?
A
Blood glucose
B
ECG
C
Troponin
D
CT head
E
Arterial blood gas
Question 10 Explanation: 
Again this is a harder question so let's break it down. The question stem is presenting you with someone having a stroke! Vertigo can be experienced as part of a stroke and so it is important to consider as part of your differentials. Now let's think about investigations in stroke. The key investigation is a CT head within 20 minutes of arrival in A&E (NICE Guidelines) to rule out a haemorrhagic stroke to enable thrombolysis to be given. Therefore, the investigation Paul immediately needs is a CT head. The other investigations may be performed but do not have the same drastic impact on management.
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