| | DIZZINESS
Doorway information about patient
the patient is a 65-year-old woman who comes to the clinic for episodes of dizziness
Vital signs
. Temperature: 36.7’C
. Blood pressure : 122/80 mmHg
. Pulse : 90 /min
. Respirations: 14/min
Approach to the patient
Dizziness encompasses a variety of syndromes involving different organ systems. The most common causes include vestibular dysfunction , cardiac / hemodynamic instability , sensor dysfunction , and psychiatric disorders . Although the patient interview can often identify the cause, even classic descriptions can be nonspecific or misleading (eg, a patient with anxiety may describe syndromes as “spinning”)
Begin by allowing patients to describe the sensation in -their own words- before asking about specific types of dizziness . Clarify the onset and course over time , associated symptoms , triggering factors , and underlying medical conditions (eg , cardiovascular , neurologic , psychiatric disorders). Confirm whether the patient lost consciousness during an episode : if so , specify the duration , time to recovery , and whether the patient suffered any injuries.
Differential diagnosis
Common causes of dizziness
Category
Primary causes
Vertigo
. -Benign paroxysmal positional vertigo-
. Vestibular neuritis
. Meziere disease
. Migraine
. Vertebrobasilar stroke
Presyncope
. -Cardiac arrhythmias-
. Aortic stenosis
. Orthostasis
. Vasovagal event
Disequilibrium
. Peripheral neuropathy
. Sensory disturbances
. Neuromuscular disorders
. Cervical spondylosis
. Central nervous system disorders
Nonspecific
. Anxiety & other psychiatric disorders
. Medications, substance abuse
. Metabolic disorders
-Vertigo_ is an abnormal sensation of motion (eg , spinning, tilting ) . The most common causes is -benign proximal positional vertigo-(BPPV) , which is provoked by change in head position . Vestibular neuritis cases prolonged vertigo . Often following a viral illness . vertigo with tinnitus , hearing loss, and a feeling of fullness in the ear suggests -Meniere disease- . -Vertebrobasilar stroke- causes debilitating vertigo , often with other neurologic deficits.
-Presyncope- is lightheadedness lasting seconds to a few minutes . it is often associated with visual disturbances and usually occurs in an upright position . Pre syncope with sweating and nausea usually represents a vasovagal event and is common in young , healthy patients. Sudden onset in a patient with cardiac disease suggests an arrthymia . Exertion symptoms suggest valvular heart disease (eg , aortic stenosis). Orthostatic symptoms are common in individuals with neuropathic conditions or taking certain medications(eg , diuretics , beta , blockers).
-Disequilibrium_ is a sense of imbalance with walking . It is typically seen in patient with sensory disorders(eg, loss of peripheral vision , peripheral neuropathy) , neuromuscular disorder, and certain central nervous system disorders (eg , Parkinson disease,, normal -pressure hydrocephalus).
HISTORY AND PHYSICAL EXAMINATION
The following sections list items that should be addressed in a patient with dizziness . Note that historical features (including the character of the dizziness and the patient’s medical history) are usually more helpful than the physical examination.
History
History of present illness
. How long have you had this spells?
. Describe what you mean by dizziness?
. How often are you having episodes & how long do they last?
. What brings on an episodes ? what makes it better or worse?
. Do you have any warning signs that an episode its about to start?
. Do changes in position (eg ,standing up) make you dizzy?
. When you get dizzy, do you have a tendency to fall?
. Do you feel like you are spinning , or the room is spinning around you ?
. Have you ever lost consciousness?
. Do you have loss of balance when walking?
. Have you had any nausea or vomiting ? headache?
. Have you had a feeling of your heart racing?
. Have you noticed changes in your hearing , or a ringing or buzzing noise in your ears?
. Do you have any double or blurry vision?
. Have you noticed any weakness in your arms or legs, or numbness in your face , arms , or legs?
. Do you have nay problems with your bowel or bladder function?
Past medical history
. Have you had a similar problem before ?
. Have you been diagnosed with any other medical conditions(eg, diabetes, hypertension)?
Social history
. Do you smoke?
. Do you drink alcohol? how much & how often?
. Have you used recreational drugs?
Physical examination
General
. Alertness, orientation & level of distress
. Body habitus & posture
HEENT
. Whisper , Rinne , Weber tests
. Otoscopic examination
Cardiovascular
. Auscultation ofr murmurs , rubs , or gallops
. Carotid upstroke & bruits
. Peripheral pulses
Neurologic
. Cranial nerves
. Muscle strength &tone
. Peripheral reflexes
. Light touch & joint position sense
. Dix-Hallpike tests
. Gait & Romberg tests
. Cerebellar signs
The -Dix-Hallpike maneuver- is specific test for BPPV. The patient is seated on the table. the head is turned 45 degrees to one side , and the patient lies back quickly . Watch the eyes for nystagmus and ask if the patient feels dizzy. In the Step 2 CS , the simulated patient may not have any objective findings , but subjective vertigo suggest BPPV
Closing the encounter
During the wrap-up discussion , review the possible diagnosis and any test that may be needed . In addition , patient with dizziness should have an assessment of safety prior to being released . Ask about any falls or injuries they may have suffered during their episodes of dizziness , and make sure their gait is stable. Also , ask what assistance they may have at home and who can help them if their symptoms worsen.
Diagnostic workup
Diagnostic testing should reflect the underlying health of the patient . A young patient with peripheral vertigo may require no testing at all , whereas an elderly patient with nonspecific dizziness may need an extensive workup . Focus on the most likely system rather than taking an unfocused , “shotgun”approach.
An ECG should be ordered in all patients with suspected arrhythmias or other cariogenic causes.
Additional studies might include:
. Fasting glucose
. Electrolytes ,blood urea nitrogen , creatinine
. Compels blood count
. Echocardiogram
. CT scan or MRI of the brain
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2018/06/05 10:42pm 
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