Dizziness resident survival guide: Difference between revisions
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==Overview== | ==Overview== | ||
[[Dizziness]] is a complex and subjective complaint that encompasses a wide [[spectrum]] of [[symptomatology]]. It is one of the most common presenting [[symptoms]] among patients seen by emergency medical [[physicians]], [[primary care]] physicians, [[neurologists]], and [[otolaryngologists]]. | [[Dizziness]] is a complex and subjective complaint that encompasses a wide [[spectrum]] of [[symptomatology]]. It is one of the most common presenting [[symptoms]] among patients seen by emergency medical [[physicians]], [[primary care]] physicians, [[neurologists]], and [[otolaryngologists]]. | ||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
*[[Electrolyte imbalance]] | * Life-threatening causes include conditions that may result in [[death]] or permanent [[disability]] within 24 hours if left untreated. | ||
*[[Traumatic brain injury]] | |||
*[[Heatstroke]] | **[[Electrolyte imbalance]] | ||
**[[Traumatic brain injury]] | |||
**[[Heatstroke]] | |||
===Common Causes=== | ===Common Causes=== | ||
| Line 21: | Line 22: | ||
*[[Meniere's disease]] | *[[Meniere's disease]] | ||
*[[BPV]] | *[[BPV]] | ||
*[[Medication effects]] | *[[Medication-induced|Medication effects]] | ||
==Diagnosis== | |||
* Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[dizziness]] according to the American Academy of Neurology guidelines. | |||
Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[dizziness]] according to the American Academy of Neurology guidelines. | |||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
| Line 47: | Line 48: | ||
==Do's== | ==Do's== | ||
*Always ask the patient what do they mean by dizziness. Dizziness may have a different meaning among patients; while vertigo may represent a vestibular condition, presyncope directs to a cardiovascular problem, or disequilibrium a neurological or psychiatric one. | *Always ask the patient what do they mean by [[dizziness]]. [[Dizziness]] may have a different meaning among patients; while [[vertigo]] may represent a [[Vestibular function|vestibular]] condition, [[presyncope]] directs to a [[cardiovascular]] problem, or [[disequilibrium]] a [[neurological]] or [[Psychiatric Disorders|psychiatric]] one. | ||
*Intentionally ask for any history of possible intoxication, medications used, and exposures. A full history review may disclose dizziness due to trauma or an intoxication. | *Intentionally ask for any history of possible [[intoxication,]] medications used, and exposures. A full history review may disclose [[dizziness]] due to [[trauma]] or an [[intoxication]]. | ||
*Ask for any eliciting or exacerbating features. Dix-Hallpike maneuver may easily detect a benign paroxysmal positional vertigo and differentiate it from a orthostatic hypotension. | *Ask for any eliciting or exacerbating features. [[Dix-Hallpike test|Dix-Hallpike]] maneuver may easily detect a [[benign paroxysmal positional vertigo]] (BPPV) and differentiate it from a [[orthostatic hypotension]]. | ||
*Perform a full neurological examination. A head-impulse, nystagmus, test of skew (HINTS) can differentiate between a central from a peripheral cause. | *Perform a full [[neurological examination]]. A head-impulse, [[nystagmus]], test of skew (HINTS) can differentiate between a central from a peripheral cause. | ||
*When taking vital signs, remember to measure blood pressure in standing and supine position. | *When taking [[vital signs]], remember to measure [[blood pressure]] in standing and [[supine position]]. | ||
*Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology. | *Perform a [[Romberg's test|Romberg test]]. A positive [[Romberg's test|Romberg test]] may disclose a peripheral etiology. | ||
==Don'ts== | ==Don'ts== | ||
*Do not perform imaging as as routine. | *Do not perform [[imaging]] as as routine. | ||
*Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness. | *Do not forget about [[Psychiatric Disorders|psychiatric]] causes. Many times [[Psychiatric Disorders|psychiatric conditions]], such as [[panic attacks]], may mimic [[dizziness]]. | ||
*Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to vessels rigidity (arteriosclerosis). | *Do not forget abut [[orthostatic hypotension]]. [[Orthostatic hypotension]] is a very common cause of [[dizziness]], especially in [[Elderly|elderly people]] due to [[blood vessels]] rigidity ([[arteriosclerosis]]). | ||
*Do not miss | *Do not miss [[Transient ischemic attack|transiten ischemic attack]] (TIA). [[TIA]] is one of the most missed [[diagnosis]] when a patient presents with [[dizziness]]. | ||
*When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. | *When looking after [[Benign paroxysmal positional vertigo|benign paroxysmal vertigo]] (BPV), do not perform [[Dix-Hallpike test|Dix-Hallpike]] only once. [[Benign paroxysmal positional vertigo|BPPV]] only comes positive in around 70% of the times with first attempt, several attempts may be necessary. | ||
*Do not give any kind of pharmacologic treatment for | *Do not give any kind of [[pharmacologic]] treatment for [[Benign paroxysmal positional vertigo|BPPV]]. | ||
==References== | ==References== | ||
{{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}} | {{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}} | ||
<references /> | <references /> | ||
Revision as of 04:35, 20 August 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.
Overview
Dizziness is a complex and subjective complaint that encompasses a wide spectrum of symptomatology. It is one of the most common presenting symptoms among patients seen by emergency medical physicians, primary care physicians, neurologists, and otolaryngologists.
Causes
Life Threatening Causes
- Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Hypotension
- Dehydration
- Hypoglycemia
- Arrhythmias
- Stroke
- Labyrinthitis
- Meniere's disease
- BPV
- Medication effects
Diagnosis
- Shown below is an algorithm summarizing the diagnosis of dizziness according to the American Academy of Neurology guidelines.
| Patient with dizzinesss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Presentation periodical or sustained? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Periodical | Sustained | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Provoked or unprovoked? | History of intoxication or trauma, or unknown? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Provoked | Unprovoked | History of intoxication | Unknown | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Apply Dix-Hallpike maneuver | Physical examination | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Deafness | Headache | Psychiatric symptoms | Barotrauma | Drugs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Positive | Negative | Meniere disease | Vestibular migraine | Panic attack, psychiatric condition | Nistagmus dominantly horizontal, direction-fixed, saccade present | Nistagmus dominantly vertical, no saccade, torsion or gaze evoked bidirectionaly | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Benign paroxysmal positional vertigo | Orthostatic hypotension | Vestibular neuritis | Stroke, transient ischemic attack | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Always ask the patient what do they mean by dizziness. Dizziness may have a different meaning among patients; while vertigo may represent a vestibular condition, presyncope directs to a cardiovascular problem, or disequilibrium a neurological or psychiatric one.
- Intentionally ask for any history of possible intoxication, medications used, and exposures. A full history review may disclose dizziness due to trauma or an intoxication.
- Ask for any eliciting or exacerbating features. Dix-Hallpike maneuver may easily detect a benign paroxysmal positional vertigo (BPPV) and differentiate it from a orthostatic hypotension.
- Perform a full neurological examination. A head-impulse, nystagmus, test of skew (HINTS) can differentiate between a central from a peripheral cause.
- When taking vital signs, remember to measure blood pressure in standing and supine position.
- Perform a Romberg test. A positive Romberg test may disclose a peripheral etiology.
Don'ts
- Do not perform imaging as as routine.
- Do not forget about psychiatric causes. Many times psychiatric conditions, such as panic attacks, may mimic dizziness.
- Do not forget abut orthostatic hypotension. Orthostatic hypotension is a very common cause of dizziness, especially in elderly people due to blood vessels rigidity (arteriosclerosis).
- Do not miss transiten ischemic attack (TIA). TIA is one of the most missed diagnosis when a patient presents with dizziness.
- When looking after benign paroxysmal vertigo (BPV), do not perform Dix-Hallpike only once. BPPV only comes positive in around 70% of the times with first attempt, several attempts may be necessary.
- Do not give any kind of pharmacologic treatment for BPPV.