2. Dizziness (Introduction) HKCEM College Tutorial Author Dr. TW Wong revised by Dr. Lam Pui Kin, Rex Oct., 2013

3. Introduction ▪ Dizziness ▪ Common Challenging ▪ And Challenging: ▪ Too many possible diagnoses ▪ Too difficult to get a clear history ▪ Physical exam is often non-contributory ▪ Too many pitfalls

4. Spectrum of Dizziness Visits to US Emergency Departments Mayo Clin Proc. 2008;83(7):765-775 Many causes:- 15%

5. Case scenario ▪ Triage ▪ F/65 ▪ dizziness today ▪ vomited once ▪ PH-- HT, DM FU GOPD ▪ BP 150/90 ▪ P 65/min ▪ Temp 37° C Category III (Stretcher case)

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

7. Some more history... ▪ Need to clarify “dizziness” ▪ your understanding on dizziness may not be the same as the patient’s.

8. 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.

9. Martin A. Samuels THE DIZZY PATIENT: A CLEAR-HEADED APPROACH In real life, it is never so neat and tidy

10. Pitfall RELYING TOO MUCH ON ASSIGNING A “DIZZINESS” CATEGORY LIMITS THE DDX. SYMPTOM DESCRIPTION IS NOT PRECISE.

11. Duration of illness ▪ 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

12. Duration of symptoms Short (minutes) ▪ BPPV ▪ Near-syncope ▪ TIA Long (hours) ▪ Vestibular neuronitis ▪ Menieres Ds Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51.

13. 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

14. Pitfall VERTIGO AGGRAVATED (NOT TRIGGERED) BY HEAD MOVEMENT MAY STILL BE DUE TO CENTRAL CAUSES.

15. Associated symptoms are useful in pointing to other DDx ▪ 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

16. 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?

17. Physical exam may help in pin pointing the cause. ▪ CNS? ▪ Peripheral vestibular? ▪ Perfusion problems?

18. Focus your exam ▪ 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 Test Gait at some point

19. Investigation ▪ No routine set of Ix for dizziness ▪ Investigations as appropriate, depends on how history and P/E lead

20. 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

21. ▪ 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 Consider CT Brain

22. 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

23. 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

24. Evaluation of dizziness History ▪ OOnset ▪ PProvoking factor ▪ QQuality or nature ▪ R Relief/Aggravate Factor ▪ SSeverity ▪ TTime Course/ Duration ▪ Associated symptoms Physical Exam ▪ Cranial N ▪ Nystagmus ▪ Cerebellar signs ▪ Gait/Balance ▪ ENT (Hallpike) ▪ CVS (postural BP) ▪ GI (tarry stool) Neuro

25. Diagnosis not to miss: STROKE (CEREBELLAR) GIB CARDIAC CAUSES Ruptured ectopic pregnancy should be considered in all female at reproductive age

26. Safe management of dizziness ▪ Precise history ▪ Repeated physical exam ▪ Choice of investigation ▪ Reassessment ▪ Discharge only if: symptom free while walking ▪ +/- referral

27. Now choose a scenario AAAA BBBB CCCC

28. THANK YOU!