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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!