Dizziness (Introduction)

HKCEM College Tutorial Dizziness(Introduction) Author Dr. TW Wongrevised 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 HISTORY Category III (Stretcher case)

Dizziness Nature Onset, duration and previous episode Severity – ability to stand, walk… Provoking and relieving factors associated symptoms PMH, Drug, Allergy Targeted history

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) • Blackout? (syncope) • Unwell? • Headache? • Weakness? • Unhappy…..?? “天旋地轉” “睜不開眼” “好想睏” “暈船浪” “想暈倒” 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.

Long history Really? Or just recurrent episodes Persisting e.g. multiple sensory deficits Recurrent e.g. Meniere’s dx Benign Paroxysmal Positional Vertigo (BPPV) Short history 1-2 days Never before Implication: look for acute sinister problem Duration of illness

Short (minutes) BPPV Near-syncope TIA Long (hours) Vestibular neuronitis Menieres Ds Duration of symptoms 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.

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 Associated symptoms are useful in pointing to other DDx

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?

GC--pallor CNS cranial N nystagmus cerebellar signs limb: motor, sensory ENT hearing Tympanic membrane Neck rigidity Carotid bruit CVS/Resp BP/P; Postural BP JVP; HS; M AE, added sounds GI abdomen PR tarry stool Focus your exam Test Gait at some point

Investigation • No routineset 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

History O Onset P Provoking factor Q Quality or nature R Relief/Aggravate Factor S Severity T Time Course/ Duration Associated symptoms Physical Exam Cranial N Nystagmus Cerebellar signs Gait/Balance ENT (Hallpike) CVS (postural BP) GI (tarry stool) Evaluation of dizziness Neuro

Diagnosis not to miss: Ruptured ectopic pregnancy should be considered in all female at reproductive age Stroke (cerebellar) GIB Cardiac causes

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!

Dizziness (Introduction)