Vertigo physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Vertigo}} | {{Vertigo}} | ||
{{CMG}}; {{AE}} {{ZMalik}} | |||
==Overview== | |||
Common physical examination findings associated with vertigo include [[nystagus]] [[hearing]] impairment , [[vision]] changes, and [[imbalance]]. | |||
== References == | [[Clinical practice guideline]]s direct the assessment<ref name="pmid37166022">{{cite journal| author=Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ | display-authors=etal| title=Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. | journal=Acad Emerg Med | year= 2023 | volume= 30 | issue= 5 | pages= 442-486 | pmid=37166022 | doi=10.1111/acem.14728 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37166022 }} </ref> using the HINTS, finger rub (for hearing assessment), and maybe STANDING protocol or ABCD<sup>2</sup> score. | ||
==Physical Examination== | |||
Physical examination of patients with vertigo is usually remarkable for [[nystagmus]], [[hearing]] impairment, [[nausea]], [[imbalance]], [[vision]] changes. | |||
===Appearance of the Patient=== | |||
*Patients with vertigo have variable general appearance depending on the underlying [[etiology]]. | |||
*Unsteady [[gait]] ([[cerebellar]] involvement), [[sensitivity]] to motion/light/[[smell]]/noise (vestibular [[migraine]]) could be observed. | |||
===Vital Signs=== | |||
*[[Blood pressure]] should be assessed to rule out [[orthostatic hypotension]]. | |||
*[[Hyperthermia]] could be associated with vestibular [[neuronitis]], [[herpes zoster oticus]], [[acute]] [[labyrinthitis]]. | |||
===Skin=== | |||
* [[Skin]] [[examination]] of [[patients]] with vertigo is usually normal. However, any [[signs]] of [[trauma]] should be assessed. | |||
===HEENT=== | |||
* [[HEENT]] [[examination]] of patients with vertigo is very important. Following [[examinations]] should be performed in every [[patient]] presenting with vertigo: | |||
**[[Otoscopic]] Exam: Can identify [[cholesteatoma]], [[herpes zoster oticus]]([[vesicles]] on [[tympanic membrane]]), [[acute]] [[otitis media]]. | |||
**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> | |||
**[[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]]. | |||
**'''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>. This test has higher [[sensitivity]] than [[neuroimaging]] in ruling out [[stroke]] as a [[cause]] of [[acute]] vertigo.<ref name="pmid30201056">{{cite journal| author=Quimby AE, Kwok ESH, Lelli D, Johns P, Tse D| title=Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department. | journal=J Otolaryngol Head Neck Surg | year= 2018 | volume= 47 | issue= 1 | pages= 54 | pmid=30201056 | doi=10.1186/s40463-018-0305-8 | pmc=6131950 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30201056 }} </ref>. Video link at YouTube - https://www.youtube.com/watch?v=VwmrjYuvqtQ | |||
**Look for evidence of [[trauma]]. | |||
**[[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> | |||
***[[Peripheral]]: Horizontal nystagmus with a torsional component, adaptive. | |||
***Central: Could be in any direction horizontal, vertical, or torsional, non-adaptive. | |||
**[[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> | |||
===Neck=== | |||
*[[Neck]] [[examination]] of [[patients]] with vertigo is usually normal. However, any [[signs]] of [[trauma]] should be assessed. | |||
===Lungs=== | |||
* [[Pulmonary]] [[examination]] of [[patients]] with vertigo is usually normal. | |||
===Heart=== | |||
* [[Cardiovascular]] [[examination]] of the [[patients]] with vertigo should include heart rate and rhythm, [[pulse]], [[blood pressure]], [[carotid]] [[bruit]], [[orthostatic]] [[blood pressure]] measurement. | |||
===Abdomen=== | |||
* [[Abdominal]] [[examination]] of [[patients]] with vertigo is usually normal. | |||
===Back=== | |||
* [[Back]] [[examination]] of [[patients]] with vertigo is usually normal. | |||
===Genitourinary=== | |||
* [[Genitourinary]] [[examination]] of [[patients]] with vertigo is usually normal. | |||
===Neuromuscular=== | |||
* [[Neuromuscular]] [[examination]] of [[patients]] with vertigo is very important in identifying the underlying [[etiology]]: | |||
*[[Patient]] is usually oriented to persons, place, and time | |||
*[[Cranial nerves]]: strength, [[sensation]], [[reflexes]] should be [[examined]]. | |||
*[[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> | |||
===Extremities=== | |||
* [[Extremities]] [[examination]] of [[patients]] with vertigo is usually normal. | |||
==References== | |||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 14:37, 17 May 2023
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]
Overview
Common physical examination findings associated with vertigo include nystagus hearing impairment , vision changes, and imbalance.
Clinical practice guidelines direct the assessment[1] using the HINTS, finger rub (for hearing assessment), and maybe STANDING protocol or ABCD2 score.
Physical Examination
Physical examination of patients with vertigo is usually remarkable for nystagmus, hearing impairment, nausea, imbalance, vision changes.
Appearance of the Patient
- Patients with vertigo have variable general appearance depending on the underlying etiology.
- Unsteady gait (cerebellar involvement), sensitivity to motion/light/smell/noise (vestibular migraine) could be observed.
Vital Signs
- Blood pressure should be assessed to rule out orthostatic hypotension.
- Hyperthermia could be associated with vestibular neuronitis, herpes zoster oticus, acute labyrinthitis.
Skin
- Skin examination of patients with vertigo is usually normal. However, any signs of trauma should be assessed.
HEENT
- HEENT examination of patients with vertigo is very important. Following examinations should be performed in every patient presenting with vertigo:
- Otoscopic Exam: Can identify cholesteatoma, herpes zoster oticus(vesicles on tympanic membrane), acute otitis media.
- Hennebert’s sign, pushing tragus provokes vertigo or nystagmus on the affected side in patients with perilymphatic fistula.[2]
- 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.
- HINTS: Head Impulse, Nystagmus, Test of Skew (cover/uncover test) to identify if the cause of vestibular neuritis is central or peripheral[3]. This test has higher sensitivity than neuroimaging in ruling out stroke as a cause of acute vertigo.[4]. Video link at YouTube - https://www.youtube.com/watch?v=VwmrjYuvqtQ
- Look for evidence of trauma.
- Nystagmus assessment is an important feature to distinguish peripheral from the central cause of vertigo:[5]
- Peripheral: Horizontal nystagmus with a torsional component, adaptive.
- Central: Could be in any direction horizontal, vertical, or torsional, non-adaptive.
- Dix-Hallpike maneuver is used to diagnose benign paroxysmal positional vertigo[6]. 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.[7]
Neck
- Neck examination of patients with vertigo is usually normal. However, any signs of trauma should be assessed.
Lungs
- Pulmonary examination of patients with vertigo is usually normal.
Heart
- Cardiovascular examination of the patients with vertigo should include heart rate and rhythm, pulse, blood pressure, carotid bruit, orthostatic blood pressure measurement.
Abdomen
- Abdominal examination of patients with vertigo is usually normal.
Back
- Back examination of patients with vertigo is usually normal.
Genitourinary
- Genitourinary examination of patients with vertigo is usually normal.
Neuromuscular
- Neuromuscular examination of patients with vertigo is very important in identifying the underlying etiology:
- Patient is usually oriented to persons, place, and time
- Cranial nerves: strength, sensation, reflexes should be examined.
- Gait imbalance should be assessed by Romberg test and tandem walking for cerebellar function.[5]
Extremities
- Extremities examination of patients with vertigo is usually normal.
References
- ↑ Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ; et al. (2023). "Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department". Acad Emerg Med. 30 (5): 442–486. doi:10.1111/acem.14728. PMID 37166022 Check
|pmid=value (help). - ↑ Rosenberg, Michael L.; Gizzi, Martin (2000). "NEURO-OTOLOGIC HISTORY". Otolaryngologic Clinics of North America. 33 (3): 471–482. doi:10.1016/S0030-6665(05)70221-8. ISSN 0030-6665.
- ↑ Tarnutzer, A. A.; Berkowitz, A. L.; Robinson, K. A.; Hsieh, Y.-H.; Newman-Toker, D. E. (2011). "Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome". Canadian Medical Association Journal. 183 (9): E571–E592. doi:10.1503/cmaj.100174. ISSN 0820-3946.
- ↑ Quimby AE, Kwok ESH, Lelli D, Johns P, Tse D (2018). "Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department". J Otolaryngol Head Neck Surg. 47 (1): 54. doi:10.1186/s40463-018-0305-8. PMC 6131950. PMID 30201056.
- ↑ 5.0 5.1 Kaski D, Seemungal BM (2010). "The bedside assessment of vertigo". Clin Med (Lond). 10 (4): 402–5. doi:10.7861/clinmedicine.10-4-402. PMC 4952176. PMID 20849021.
- ↑ Hanley K, O' Dowd T (2002). "Symptoms of vertigo in general practice: a prospective study of diagnosis". Br J Gen Pract. 52 (483): 809–12. PMC 1316083. PMID 12392120.
- ↑ Büttner U, Helmchen C, Brandt T (1999). "Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review". Acta Otolaryngol. 119 (1): 1–5. doi:10.1080/00016489950181855. PMID 10219377.