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| __NOTOC__
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| {{Vertigo}}
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| {{CMG}}; {{AE}} {{ZMalik}} | | {| class="wikitable" |
| | | !align="center" style="background: #4479BA; color: #FFFFFF | '''Common Cause of Tremor''' |
| ==Overview== | | ! align="center" style="background: #4479BA; color: #FFFFFF| '''Differentiating Feature of Tremor''' |
| Common physical examination findings associated with vertigo include [[nystagus]] [[hearing]] impairment , [[vision]] changes, and [[imbalance]]. | | ! align="center" style="background: #4479BA; color: #FFFFFF| '''Main Feature of Disease''' |
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| ==Physical Examination== | | | [[Essential tremor]] || Postural Tremor - [[Frequency]] 4–12 Hz, Bilateral onset || [[gait]] [[ataxia]], [[vestibulo-cerebellar]] involvement, reduced by [[alcohol]], [[family history]], [[stress]]/[[fatigue]] can increase tremor [[amplitude]], increases with voluntary movements |
| Physical examination of patients with vertigo is usually remarkable for [[nystagmus]], [[hearing]] impairment, [[nausea]], [[imbalance]], [[vision]] changes.
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| | | | [[Parkinson’s disease]] || [[Resting Tremor]] - Unilateral onset || [[Bradykinesia]], [[micrographia]], [[stooped posture]], [[ataxia]], [[rigidity]], [[imbalance]], [[depression]], [[apathy]], decreases with voluntary movements |
| ===Appearance of the Patient===
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| *Patients with vertigo have variable general appearance depending on the underlying [[etiology]].
| | | [[Physiologic Tremor]] || Postural tremor - High [[frequency]] 8–10 Hz, low [[amplitude]], irregular oscillations || Tremor occurs while maintaining a posture and mostly disappears if [[eyes]] are closed or a load is placed on the [[muscles]]. Subtle [[innate]] tremor normally present in the general [[population]]. |
| *Unsteady [[gait]] ([[cerebellar]] involvement), [[sensitivity]] to motion/light/[[smell]]/noise (vestibular [[migraine]]) could be observed.
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| | | | Enhanced [[Physiologic]] Tremor ||Increased [[amplitude]] ||[[Physiologic]] tremor enhanced due to [[fatigue]], [[sleep deprivation]], [[drugs]], [[endocrine disorders]], [[caffeine]], [[stress]]. |
| ===Vital Signs===
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| | | | [[Cerebellar]] Tremor || [[Intention tremor]] - Low [[frequency]] <4 Hz || Occurs in [[multiple sclerosis]], [[stroke]], [[brainstem]] [[tumor]], or [[cerebellar]] [[trauma]]. May feature [[ataxia]], [[dysmetria]], [[dysdiadochokinesia]], and [[dysarthria]]. |
| *[[Blood pressure]] should be assessed to rule out [[orthostatic hypotension]].
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| *[[Hyperthermia]] could be associated with vestibular [[neuronitis]], [[herpes zoster oticus]], [[acute]] [[labyrinthitis]].
| | | [[Drug]] Induced Tremor || Can enhance rest, action, postural tremors || [[Amiodarone]], [[bronchodilators]], [[lithium]], [[metoclopramide]], [[neuroleptics]], [[theophylline]], [[valproate]] |
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| ===Skin===
| | | [[Orthostatic]] Tremor || [[Essential tremor]] variant, high [[frequency]] 14 Hz-18 Hz|| Occurs in the [[legs]] on standing and is relieved by sitting down |
| * [[Skin]] [[examination]] of [[patients]] with vertigo is usually normal. However, any [[signs]] of [[trauma]] should be assessed.
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| | | |Holmes tremor || Combination of rest, action, and postural tremors, [[Frequency]] 2Hz-5Hz || Mostly due to [[vascular]] [[lesion]] in [[mesencephalic]], [[thalamic]] or both regions. |
| ===HEENT===
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| * [[HEENT]] [[examination]] of patients with vertigo is very important. Following [[examinations]] should be performed in every [[patient]] presenting with vertigo:
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| **[[Otoscopic]] Exam: Can identify [[cholesteatoma]], [[herpes zoster oticus]]([[vesicles]] on [[tympanic membrane]]), [[acute]] [[otitis media]].
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| **Hennebert’s sign, pushing tragus provokes vertigo or [[nystagmus]] on the affected side in patients with [[perilymphatic fistula]].<ref name="RosenbergGizzi2000">{{cite journal|last1=Rosenberg|first1=Michael L.|last2=Gizzi|first2=Martin|title=NEURO-OTOLOGIC HISTORY|journal=Otolaryngologic Clinics of North America|volume=33|issue=3|year=2000|pages=471–482|issn=00306665|doi=10.1016/S0030-6665(05)70221-8}}</ref>
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| **[[Hearing]]: Weber or Rinne's test is done in the [[clinic]] or at the bedside to determine if it is conductive or [[sensorineural hearing loss]].
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| **'''HINTS''': '''H'''ead '''I'''mpulse, '''N'''ystagmus, '''T'''est of '''S'''kew (cover/uncover test) to identify if the cause of [[vestibular neuritis]] is central or peripheral.<ref name="TarnutzerBerkowitz2011">{{cite journal|last1=Tarnutzer|first1=A. A.|last2=Berkowitz|first2=A. L.|last3=Robinson|first3=K. A.|last4=Hsieh|first4=Y.-H.|last5=Newman-Toker|first5=D. E.|title=Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome|journal=Canadian Medical Association Journal|volume=183|issue=9|year=2011|pages=E571–E592|issn=0820-3946|doi=10.1503/cmaj.100174}}</ref>
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| **Look for evidence of [[trauma]].
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| **[[Nystagmus]] assessment is an important feature to distinguish peripheral from the central cause of vertigo:<ref name="pmid20849021">{{cite journal| author=Kaski D, Seemungal BM| title=The bedside assessment of vertigo. | journal=Clin Med (Lond) | year= 2010 | volume= 10 | issue= 4 | pages= 402-5 | pmid=20849021 | doi=10.7861/clinmedicine.10-4-402 | pmc=4952176 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20849021 }} </ref>
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| ***[[Peripheral]]: Horizontal nystagmus with a torsional component, adaptive.
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| ***Central: Could be in any direction horizontal, vertical, or torsional, non- adaptive.
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| **[[Dix-Hallpike maneuver]] is used to diagnose [[benign paroxysmal positional vertigo]]<ref name="pmid12392120">{{cite journal| author=Hanley K, O' Dowd T| title=Symptoms of vertigo in general practice: a prospective study of diagnosis. | journal=Br J Gen Pract | year= 2002 | volume= 52 | issue= 483 | pages= 809-12 | pmid=12392120 | doi= | pmc=1316083 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12392120 }} </ref>. [[Dix-Hallpike maneuver]] can also differentiate between central and peripheral, the intensity of induced symptom decreases with repeated [[maneuvers]] in peripheral but less likely to decrease if the lesion is central in origin.<ref name="pmid10219377">{{cite journal| author=Büttner U, Helmchen C, Brandt T| title=Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. | journal=Acta Otolaryngol | year= 1999 | volume= 119 | issue= 1 | pages= 1-5 | pmid=10219377 | doi=10.1080/00016489950181855 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10219377 }} </ref>
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| ===Neck===
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| *[[Neck]] [[examination]] of [[patients]] with vertigo is usually normal. However, any [[signs]] of [[trauma]] should be assessed.
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| ===Lungs===
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| * [[Pulmonary]] [[examination]] of [[patients]] with vertigo is usually normal.
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| ===Heart===
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| * [[Cardiovascular]] [[examination]] of the [[patients]] with vertigo should include heart rate and rhythm, [[pulse]], [[blood pressure]], [[carotid]] [[bruit]], [[orthostatic]] [[blood pressure]] measurement.
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| ===Abdomen===
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| * [[Abdominal]] [[examination]] of [[patients]] with vertigo is usually normal.
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| ===Back===
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| * [[Back]] [[examination]] of [[patients]] with vertigo is usually normal.
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| ===Genitourinary===
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| * [[Genitourinary]] [[examination]] of [[patients]] with vertigo is usually normal.
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| ===Neuromuscular===
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| * [[Neuromuscular]] [[examination]] of [[patients]] with vertigo is very important in identifying the underlying [[etiology]]:
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| *[[Patient]] is usually oriented to persons, place, and time
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| *[[Cranial nerves]]: strength, [[sensation]], [[reflexes]] should be [[examined]].
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| *[[Gait]] [[imbalance]] should be assessed by[[Romberg]] test and tandem walking for [[cerebellar]] [[function]].<ref name="pmid20849021">{{cite journal| author=Kaski D, Seemungal BM| title=The bedside assessment of vertigo. | journal=Clin Med (Lond) | year= 2010 | volume= 10 | issue= 4 | pages= 402-5 | pmid=20849021 | doi=10.7861/clinmedicine.10-4-402 | pmc=4952176 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20849021 }} </ref>
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| ===Extremities===
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| * Extremities examination of patients with [disease name] is usually normal.
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| OR
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| *[[Clubbing]]
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| *[[Cyanosis]]
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| *Pitting/non-pitting [[edema]] of the upper/lower extremities
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| *Muscle atrophy
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| *Fasciculations in the upper/lower extremity
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| ==References==
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| {{Reflist|2}}
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| {{WH}}
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| {{WS}}
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| [[Category: (name of the system)]] | |