Dizziness

Dizziness

Dizziness is a common yet another vague symptom that patients may report to their primary care providers. It was previously classified under the following categories: vertigo, presyncope, disequilibrium, and light-headedness. However, this classification is no longer recommended for diagnostic evaluation because patients may not be able to provide precise features of their symptoms to fit under one of the above categories (2). Although, majority of them will have benign causes of dizziness, its very imperative to rule out other life-threatening causes.

Stage 1

Abstract Conceptualization

Abstract Conceptualization

Stage-2

Active Experimentation

Active Experimentation

History Collection and Patient Assessment

‘Timing, Triggers, and Target approach’ is the recommendedapproach to diagnostic evaluation (2). Collect patient’s medical history to identify if there are any pre-existing cardio pulmonary conditions, diabetes, or anemia. Patients with COPD or lung conditions are at risk of dizziness due to hypoxemia. Check if he/ she is on any antihypertensives, antiarrythmic, antihyperglycemic drugs. Collect history related to possible substance abuse, ETOH abuse, or use of herbal supplements. Is the dizziness associated with any headache, hearing loss or recent h/o viral URTI? Also inquire whether the patient has experienced any symptoms such as palpitation, syncope, seizure activity, aura etc. Always rule out if any use of antihyperglycemic drugs and associated hypoglycemia. Patients with eating disorders may experience dizziness due to hypoglycemia. Psychogenic causes of dizziness should be evaluated in high risk patients when other causes are ruled out.

Physical examination

Check Vital signs

Measure BP in supine and standing, note the difference in values

Complete neurological, cardiologic, and ENT assessment

Consider ordering CBC,ferritin,A1c, b12 if anemia, diabetes, or b12 deficiency is suspected. Patient with history of palpitations, syncope, or high cardiovascular risk will benefit from cardio vascular assessment/investigations. If paroxysmal atrial fibrillation is suspected, consider ordering cardiac loop monitoring.Patients with syncope require further evaluation to rule out vasovagal syncope vs other systemic or metabolic reasons ( syncope management is not included in this module).

Perform HINTS assessment (Head impulse, nystagmus, test of skew) to r/o central vs peripheral causes of vertigo. A video demonstrating the examination is available at:

Include Dix Hallpike maneuver if BPPV is suspected; watch the video at:

Vertigo -- A sense of moving sensation when not moving, or a sense of self motion during head movement is called vertigo which is the result of asymmetry within the vestibular system or a disorder of peripheral labyrinth or its inner connections.

Meniere’s disease-Vertigo associated with sensorineural hearing loss in the affected ear with tinnitus or aural fullness.

BPPV- It is triggered with quick position changes; e. g: quick turn of head, tipping the head back in the shower etc. BPPV occurs as result of loose otoconia that dislodges and enter in the semicircular canal (1).

Orthostatic hypotension: It occurs with quick movement to upright from supine.A drop in systolic BP by 20mm hg and diastolic by 10mm hg after going from supine to standing support the diagnosis of possible orthostatic hypotension (3).

Vestibular neuritis: Severe rotatory vertigo with nausea and movements of objects in the visual filed, horizontal nystagmus, or unsteady gait with tendency to fall are the classical features of vestibular neuritis.

Episodic vertigo in a patient with h/o migraine headache suggests vestibular migraine. Rule out other central etiology by doing neurological exam, HINTS exam (4).

In the absence of any other causes and associated psychiatric conditions, rule of psychogenic causes

Clinical Management

Meiners disease is managed with low salt diet and diuretic use

BPPV is treated with Epley maneuver.

Vestibular neuritis is treated with medications and vestibular rehabilitation

CT brain is not recommended unless positive neurological conditions are suspected.

Pharmaceutical management of vestibular neuritis, Meniere’s disease, BPPV is available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613190/ ( table 2)

Stage 3

Concrete Experimentation

Concrete Experimentation

SOAP note sample

c/o dizziness x 3 days

mild otalgia, aural fulness (left)

no h/o trauma

feeling disequilibrium

recent h/o viral URTI

has been coughing, sneezing

no tinnitus

decreased hearing in left ear

no chest pain, palpitations

medications- nil

o/e

nad

BP: 120/80mmhg

CVS-wnl, no ehs, s1s2-wnl, no murmurs

RS-clear,GAEBl, no adventitious breath sounds

ENT- TMs- left rupture, partially, no bulging/erythema/opacity, conjunctiva n, no erythema/eye discharge, oropharynx n, no tonsillar enlargement/exudate, no LAD, no nuchal rigidity

Neuro: Neuro: perrla, cn 2-12 grossly n, eom n, strength 5/5, muscle tone grossly n, sens/coord/ref grossly n, no tremor/rigidity/bradykinesia, gait n, no nuchal rigidity

A

Disequilibrium sec to ruptured TM

P

Watchful waiting

Reassurance given that often ruptured TM heals without any interventions

ENT referral

Discussed fall/ injury prevention

Stage - 4

Reflective Observation

Reflective Observation

Learner Activity

Write a reflection on your learning experience with dizziness management? Present a case/ cases to explain the learning outcome; use Kolb’s learning cycle to explain your learning transition through the stages of learning cycle.

Reference

Parnes, L., Sumit, K., Agrawal, & Jason, A. (2003)., Diagnosis and management of benign paroxysmal positional vertigo. CMAJ September 30,169 (7): 681-693.Retrieved from http://www.cmaj.ca/content/169/7/681.short

Munice, H., Sirmans, S., James, E, (2017)., Dizziness: Approach to Evaluation and Management. American Family Physician. Feb 1;95(3):154-162.

Dros,J., Otto, R., Maarsingh, Henriëtte, E., Horst, V., Patrick, J., Bindelsetal.( 2010). Tests used to evaluate dizziness in primary care. CMAJ September 21, 182 (13) E621-E631. Retrieved from http://www.cmaj.ca/content/182/13/E621

Kerber, K. A., & Baloh, R. W. (2011). The evaluation of a patient with dizziness. Neurology. Clinical practice, 1(1), 24-33. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613190/ ( table 2)