Dizziness(Introduction)

Report
HKCEM College Tutorial
Dizziness
(Introduction)
Author
Dr. TW Wong
revised by
Dr. Lam Pui Kin, Rex
Oct., 2013
Introduction
▪ Dizziness
▪ Common
▪ And Challenging:
▪Too many possible diagnoses
▪Too difficult to get a clear history
▪Physical exam is often non-contributory
▪Too many pitfalls
Many causes:-
15%
Spectrum of Dizziness Visits to US Emergency Departments
Mayo Clin Proc. 2008;83(7):765-775
Case scenario
▪ Triage
▪ F/65
▪ dizziness today
▪ vomited once
▪ PH-- HT, DM FU GOPD
▪ BP 150/90
▪ P 65/min
▪ Temp 37° C
Category III (Stretcher case)
Targeted history
▪ Dizziness
▪ Nature
▪ Onset, duration and previous episode
▪ Severity – ability to stand, walk…
▪ Provoking and relieving factors
▪ associated symptoms
▪ PMH, Drug, Allergy
Some more history...
▪ Need to clarify “dizziness”
▪ your understanding on dizziness may not be
the same as the patient’s.
What does the patient mean by the term “dizziness”?
▪ Vertigo? (an illusion of motion)
▪ Disequilibrium? (tend to fall)
▪ Lightheadedness? (pre-syncope)
“天旋地轉”
▪ Blackout? (syncope)
“睜不開眼”
“好想睏”
“暈船浪”
“想暈倒”
▪ Unwell?
▪ Headache?
▪ Weakness?
▪ Unhappy…..??
Try not to use the word “dizziness” to describe your feeling.
In real life, it is never so neat and tidy
Martin A. Samuels
THE DIZZY PATIENT: A CLEAR-HEADED APPROACH
Pitfall
RELYING TOO MUCH ON ASSIGNING A
“DIZZINESS” CATEGORY LIMITS THE DDX.
SYMPTOM DESCRIPTION IS NOT PRECISE.
Duration of illness
▪ Long history
▪ Short history
▪ 1-2 days
▪ Really?
▪ Never before
▪ Or just recurrent episodes
▪ Persisting e.g. multiple sensory
deficits
▪ Recurrent e.g.
▪ Implication: look for
▪ Meniere’s dx
acute sinister problem
▪ Benign Paroxysmal Positional Vertigo (BPPV)
Duration of symptoms
Short (minutes)
Long (hours)
▪ BPPV
▪ Vestibular neuronitis
▪ Near-syncope
▪ Menieres Ds
▪ TIA
Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51.
Provoking/Precipitating factors
▪ Triggered by certain head position e.g. looking up
▪ Positional vertigo (e.g. BPPV)
▪ Triggered by change in head position
▪ Likely peripheral vestibular
▪ Worsen while getting up and lying down
▪ Equivalent to change head position
▪ Worsen while getting up only
▪ Think orthostatic hypotension, autonomic neuropathy
▪ Only while walking
▪ Likely neurological deficit
▪ During exercise
▪ Perfusion problem due to CV causes
Pitfall
VERTIGO AGGRAVATED (NOT TRIGGERED) BY HEAD
MOVEMENT MAY STILL BE DUE TO CENTRAL CAUSES.
Associated symptoms are useful in
pointing to other DDx
▪ General
▪ Fever (URI)
▪ Nausea
▪ Depression / anxiety
▪ CNS
▪
▪
▪
▪
headache
diplopia
weakness/numbness
unsteady gait
▪ CVS/Resp
▪ palpitation
▪ chest pain
▪ SOB, cough
▪ ENT
▪ earache, fullness
▪ hearing loss
▪ tinnitus
▪ GI
▪ Vomiting/ Diarrhea
▪ Abdominal pain
▪ tarry stool
Drug related dizziness
▪ Hypotension
▪ All anti HT drugs (especially recently added)
▪ postural hypotension: alpha-blockers
▪ Hypoglycemia
▪ Long acting DM drug: Daonil for age>70
▪ Toxic action at reticular activating system
▪ Anticonvulsant e.g. phenytoin
▪ + nystagmus
▪ Drugs that disturb electrolytes: Natrilix
▪ Ototoxic drugs: lasix, salicylates
Ask for recent increase in
dosage of usual
medications?
Any OTC Medications?
Any herbal remedies?
Physical exam may help in pin
pointing the cause.
▪ CNS?
▪ Peripheral vestibular?
▪ Perfusion problems?
Focus your exam
▪ GC--pallor
▪ CNS
▪ cranial N
▪ nystagmus
▪ cerebellar signs
▪ limb: motor, sensory
▪ ENT
▪ hearing
▪ Tympanic membrane
▪ Neck
▪ rigidity
▪ Carotid bruit
Test Gait at
some point
▪ CVS/Resp
▪ BP/P; Postural BP
▪ JVP; HS; M
▪ AE, added sounds
▪ GI
▪ abdomen
▪ PR tarry stool
Investigation
▪ No routine set of Ix for dizziness
▪ Investigations as appropriate, depends on how
history and P/E lead
Useful investigations for dizziness
▪ ECG: suspected silent MI ( usually in diabetic and old female ) or
arrhythmia
▪ Blood glucose: hyper/hypo in DM patients
▪ CBP: suspected anemia
▪ Electrolytes: maybe useful in patients with non-specific dizziness
and risk factors e.g. on diuretics
▪ CT brain
▪ Bedside USG: if AAA/ectopic pregnancy suspected
Consider CT Brain
▪ Age >50
▪ Abrupt onset of symptoms
▪ Prior history of stroke/TIA
▪ Risk factors for stroke
▪ Head/ Neck injury (MVC, neck manipulation ? Dissection)
▪ Headache (sudden, severe, persistent)
▪ Nausea/vomiting disproportionate to dizziness
Wait 24-48 h before CT
▪ Isolated vertigo
▪ Nystagmus of peripheral type
▪ Can still walk though unstable
▪ If symptoms improve over time  vestibular
disease and no need for CT
Summary
We have covered:
▪ Different types of dizziness
▪ Important causes of dizziness
▪ Vertigo: stroke, vestibular ds
▪ non-vertigo: inadequate CNS perfusion, anemia…
▪ Evaluation of dizzy patients
Evaluation of dizziness
History
Physical Exam
▪O
Onset
▪ Cranial N
▪P
Provoking factor
▪ Nystagmus
▪Q
Quality or nature
▪ Cerebellar signs
▪R
Relief/Aggravate Factor
▪ Gait/Balance
▪S
Severity
▪ ENT (Hallpike)
▪T
Time Course/ Duration
▪ CVS (postural BP)
▪ Associated symptoms
▪ GI (tarry stool)
Neuro
Diagnosis not to miss:
STROKE (CEREBELLAR)
GIB
CARDIAC CAUSES
Ruptured ectopic pregnancy should be
considered in all female at reproductive age
Safe management of dizziness
▪ Precise history
▪ Repeated physical exam
▪ Choice of investigation
▪ Reassessment
▪ Discharge only if: symptom free while walking
▪ +/- referral
Now choose
a scenario
A
B
C
THANK YOU!

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