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DIZZINESS Module # 2 Evaluation

DIZZINESS Module # 2 Evaluation. Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512. PROCESS. Series of modules and questions Step #1: Power point module with voice overlay

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DIZZINESS Module # 2 Evaluation

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  1. DIZZINESSModule # 2Evaluation Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512

  2. PROCESS Series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

  3. Objectives Upon completion of the module the learner will be able to: • List the key historical elements to evaluate dizziness • Describe the four areas to evaluate in the physical exam • Describe the performance of the Nystagmus exam • List diagnostic tests for dizziness and indications

  4. EVALUATION Recommended: • Brief, focused evaluation and simple follow-up Why? Most symptoms subside Reminder: 75% cases diagnosed history and physical examination Hoffman R., Einstadter D., Kroenke K. Evaluating dizziness . Am J. Med 1999; 107: 468-478

  5. Practical Approach to Evaluating the Dizzy Patientpage one History • Step #1 Ask patient to describe symptoms • Step #2 Did you pass out?” ( syncope often requires early cardiac evaluation) • Step # 3 Attempt to classify into 3 key sensations: (spinning, fainting or falling?) • Step #4 Positional effect on symptoms? • - worsen with head movements? (eg, benign positional vertigo) • - standing up (eg, orthostatic hypotension) • - associated with ambulating (eg, disequilibrium) Kroenke K, Hoffman RM, Einstadter D. How common are various causes of dizziness? A critical review. South Mud J. 2000;93(2):160-167.

  6. Practical Approach to Evaluating the Dizzy Patientpage two Step # 5 Associated symptoms • syncope ( needs syncope eval.) • nausea or vomiting ( vertigo) • hearing, ear symptoms ( Meniere's disease, acoustic neuroma) • ataxia or focal neurologic deficits (Central neurological cause) • multiple somatic complaints (depression, anxiety, somatoform disorder) • Step #6 Medications review: (especially ones initiated around the time of onset of dizziness symptoms)

  7. Practical Approach to Evaluating the Dizzy Patientpage three PHYSICAL EXAM 5 main areas to evaluate: Orthostatic BP and pulse Nystagmus exam Brief cardiovascular exam Brief neurologic exam Vision and hearing

  8. Practical Approach to Evaluating the Dizzy Patientpage four PHYSICAL EXAM Orthostatic blood pressure and pulse • BP & pulse: supine, then standing for ~ 2 minutes

  9. PHYSICAL EXAM Nystagmus exam: 1st Primary position 2nd Gaze-evoked 3rd Dix-Hallpike test 4th Head-shaking

  10. PHYSICAL EXAMNystagmus exam: 1st Primary position • patient look straight ahead & look for nystagmus 2nd Gaze-evoked Test: • Patient look: right, left, up, and down • Hold each position for 5 -10 seconds (positive: > three to five beats nystagmus)

  11. 3rd Dix-Hallpike test Test seat patient on exam table, explain: to look straight ahead and keep eyes open and to alert you if symptoms of “their dizziness” occurs place pillow on exam table to point where shoulder blades will rest help them lie down quickly with one ear turned toward the table and observe eyes for nystagmus for 5-10 secs. help to a sitting position (again observe eyes for 5-10 secs) repeat the maneuver with the other ear turned toward the table. 4th Head-shaking Test patient close eyes rapidly shake the head back and forth for 10 seconds then open eyes and look for nystagmus. PHYSICAL EXAMNystagmus exam:

  12. Cardiovascular exam(murmurs, abnormal rhythm) Neurologic (cerebellar, propioception, motor, sensory) (include “Up and Go” test Vision & Hearing PHYSICAL EXAMCardiac and neurological exams

  13. Diagnostic Testing Lab tests: CBC, Chem.Profile, TSH, VDRL • (low yield without other associated indications) EKG: • commonly obtained in older patients with cardiovascular risk factors • (low diagnostic value in patients with a normal cardiac examination and non-syncopal dizzines)

  14. Audiometry: Indicated with cochlear symptoms, (e.g. tinnitus, asymmetric hearing loss) Vestibular testing: electronystagmography (ENG) has important limitations Diagnostic Testing

  15. Diagnostic Testing Other tests: Brain stem auditory evoked responses Rotatory chair Dynamic posturography • The latter two tests may substitute for or augment ENG in special situations, but testing for brain stem auditory evoked responses is occasionally indicated if clinical evaluation, audiometry, or ENG suggest a central vestibulopathy. Neuroimaging (MRI best for posterior fossa)

  16. Diagnostic Testing Electroencephalography (EEG) is typically not useful Carotid Ultrasound warranted only if other neurological symptoms suggest transient ischemic attacks Other Cardiac tests Holter and event monitors, echocardiography, stress testing, tilt-tables and electrophysiologic studies • only helpful in syncope

  17. THE APPROACH Remember: start with Brief, focused evaluation and simple follow-up) • Assume multi-factorial • Classify Symptoms • List Factors derived from “ Classification) and their etiologies • Treat multiple factors and the easiest first • Time is on your side ( go slow), see patient back often Tinnetti ME, et. al. Annls Intern Med. 7 Mar. 2000, Vol. 132: No. 5, 337-344

  18. The End of Module Two on Evaluation of Dizziness

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