π΅βπ« Approach to Dizziness! π΅βπ«
4 big buckets:
- Pre-syncope
- Vertigo
- Imbalance/Dysequilibrium
- Psychiatric
This approach is very much a bird's eye view approach that should assist in history/data acquisition. I'll also cover a tricky don't-miss Dx.
4 big buckets:
- Pre-syncope
- Vertigo
- Imbalance/Dysequilibrium
- Psychiatric
This approach is very much a bird's eye view approach that should assist in history/data acquisition. I'll also cover a tricky don't-miss Dx.
Dizziness 2/2 Pre-syncope:
π΄ History: "lightheadedness"
π΄ Pre-syncope DDx is stratified by the classic approach to syncope (orthostatic hypotension, reflex, cardiac)
Let's touch more on orthostatic hypotension, as this is not an endpoint Dx.
π΄ History: "lightheadedness"
π΄ Pre-syncope DDx is stratified by the classic approach to syncope (orthostatic hypotension, reflex, cardiac)
Let's touch more on orthostatic hypotension, as this is not an endpoint Dx.
Orthostatic hypotension = β in systolic BP β₯ 20 mmHg / β₯ 10 mmHg in diastolic BP
Neurogenic etiologies 2/2 autonomic dysfunction are marked by:
π΄ No HR β / vasoconstriction upon standing
π΄ Supine hypertension
π΄ Post-prandial symptoms (splanchnic pooling)
Neurogenic etiologies 2/2 autonomic dysfunction are marked by:
π΄ No HR β / vasoconstriction upon standing
π΄ Supine hypertension
π΄ Post-prandial symptoms (splanchnic pooling)
Non-neurogenic etiologies show a 1:1 HR response to βin BP (mmHg).
Consider:
π΄ Hypovolemia (hemorrhage, β intake, β losses)
π΄ Medications (alpha blockers, psychiatric meds)
Consider:
π΄ Hypovolemia (hemorrhage, β intake, β losses)
π΄ Medications (alpha blockers, psychiatric meds)
The remaining buckets encompass numerous disorders:
π£ Vertigo (spinning/tilting sensation, often present w/ eyes closed)
π‘ Imbalance/Proprioception (worse when standing/walking & improves w/ hand grip stabilization)
π΅ Psychiatric (panic/anxiety β hyperventilation)
π£ Vertigo (spinning/tilting sensation, often present w/ eyes closed)
π‘ Imbalance/Proprioception (worse when standing/walking & improves w/ hand grip stabilization)
π΅ Psychiatric (panic/anxiety β hyperventilation)
Patient history consistent with a specific etiology should prompt targeted testing.
BUT!
Patient descriptions are inconsistent & don't correlate well w/ underlying etiology; therefore, a more consistent Dx approach is to categorize dizziness as Acute vs. Chronic.
BUT!
Patient descriptions are inconsistent & don't correlate well w/ underlying etiology; therefore, a more consistent Dx approach is to categorize dizziness as Acute vs. Chronic.
I said I'd cover a tricky don't miss Dx: let's step into the world of acute, continuous dizziness.
DDx = posterior circulation stroke (!) vs. vestibular neuritis (benign)
If patient remains acutely dizzy, perform HINTS exam: youtube.com
DDx = posterior circulation stroke (!) vs. vestibular neuritis (benign)
If patient remains acutely dizzy, perform HINTS exam: youtube.com
If dizziness is continuous & chronic, consider the following work-up:
π΅βπ« Anemia β CBC
π΅βπ« Medications β Rx review
π΅βπ« Posterior fossa lesion β Head imaging
π΅βπ« Anemia β CBC
π΅βπ« Medications β Rx review
π΅βπ« Posterior fossa lesion β Head imaging
Summary:
π Dizziness DDx = pre-syncope, vertigo, imbalance/dysequilibrium, psychiatric
π Orthostatic hypotension is not an endpoint Dx
π Patient descriptions are inconsistent. If acute & continuous dizziness (vertigo), perform HINTS to assess for posterior circ. stroke
π Dizziness DDx = pre-syncope, vertigo, imbalance/dysequilibrium, psychiatric
π Orthostatic hypotension is not an endpoint Dx
π Patient descriptions are inconsistent. If acute & continuous dizziness (vertigo), perform HINTS to assess for posterior circ. stroke
More thorough Dx approach to dizziness by @AaronLBerkowitz here. Buy his fantastic book!
References:
1) Dr. John Chang (all-star clinician educator @YaleIM_Chiefs)
2) n.neurology.org
3) accessmedicine.mhmedical.com by @AaronLBerkowitz
4) youtube.com
1) Dr. John Chang (all-star clinician educator @YaleIM_Chiefs)
2) n.neurology.org
3) accessmedicine.mhmedical.com by @AaronLBerkowitz
4) youtube.com
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