EMQs in Clinical Medicine.pdf - Peshawar Medical College

Headache – answers 89
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A 50-year-old man presents with vertigo when rolling over quickly in
bed, getting out of bed and bending over. His hearing is normal.
Benign paroxysmal positional vertigo is characterized by short episodes
of vertigo triggered by head movements. Patients often report problems
when rolling over in bed/getting out of bed. It is caused by free-floating
particles in the endolymph of the semicircular canal which in turn cause
continuing stimulation of the auditory canal for several seconds after
movement of the head has ceased.
Hallpike’s manoeuvre is used to confirm the diagnosis of benign paroxysmal
positional vertigo. The patient is asked to sit upright with the head
facing the examiner. The examiner grasps the patient’s head between his
hands and rapidly moves the patient from a sitting to lying position with
the head tipped below the horizontal plane, 45˚ to the side, and with the
side of the affected ear (and semicircular canal) downwards.
A positive test provokes vertigo and rotatory nystagmus that typically
has a latency of a few seconds before onset and fatigues after about 30 s.
If the nystagmus appears immediately on performing the manoeuvre and
does not fatigue, a cerebellar mass lesion may be responsible and computed
tomography (CT) should be performed.
The condition can be treated with the Epley manoeuvre (orient the head
in various positions to displace the particles from the posterior canal).
A 20-year-old man presents with vertigo having suffered with symptoms
of flu for several days.
Vestibular neuronitis is associated with a preceding infection/illness. The
vertigo is severe and presents abruptly with vomiting but no
deafness/tinnitus. The vertigo usually diminishes after a few days and in
many cases there is complete recovery within a couple of weeks. Some
individuals, however, develop benign paroxysmal positional vertigo
afterwards.
29 Headache
Answers: F A L J B
F
A 40-year-old man complains of severe headache of sudden onset 4 h
ago, likened to being kicked in the back of the head. He has vomited
twice and is now feeling stiff in his neck.
Subarachnoid haemorrhage is usually caused by rupture of berry
aneurysms found on the circle of Willis. Disease states associated with
high blood pressure, e.g. coarctation of aorta, polycystic disease or defective
collagen synthesis, e.g. Ehlers–Danlos syndrome, predispose to berry
aneurysm formation.
Typical symptoms are of a severe occipital headache that is sometimes
likened to being ‘kicked in the back of the head’.