Patient History Most Important Factor in Diagnosing Dizziness

Terry Hartnett

September 30, 2006

September 30, 2006 (Washington) — Physicians see at least several patients a week with symptoms of dizziness. But the lack of a simple lab test or other diagnostic measure makes it hard to determine the best approach to treating these patients, according to Coleen Martin, MD, a family practice physician in Ankenny, Iowa. Dr. Martin, like many of her fellow physicians, worries that she may be overlooking something more serious when a patient presents with dizziness.

Although serious conditions can manifest with dizziness, most of the time it is more debilitating for the patient than a cause for alarm. The root cause of dizziness in half of all patients with symptoms is benign paroxysmal positional vertigo (BPPV), said Suraj Achar, MD, assistant clinical professor and educational director of the sports medicine fellowship program at the University of California San Diego School of Medicine during a presentation here at the Scientific Symposium of the American Academy of Family Physicians (AAFP).

Dr. Achar said patient history is the most important factor in making a diagnosis for the patient with dizziness. The length of time and persistence of the dizziness are also important to assess. The first step in diagnosing a patient who reports having dizziness is to rule out the more serious possibilities. These include traumatic brain injury (TBI) and other central nervous system conditions such as brain tumor, Meniere's disease, and cardiac-related problems.

Dizziness that has lasted for a prolonged period of time could be the result of a brain stem tumor. If this is suspected, magnetic resonance imaging should be performed, Dr. Achar said. In the event of TBI, the patient will also likely have vomiting and severe headache. Send the patient to the hospital immediately. Computed tomography is the best diagnostic measure within 24 hours of injury. Dr. Achar urged physicians not to use a triptan to treat a patient with suspected migraine headache and dizziness until brain tumor has been eliminated as the cause.

Presyncope is another possible cause for dizziness, said Dr. Achar. The history, in this case, will show that the dizziness, and even possible falling, is usually a single episode that lasts under one minute. In some instances, the patient may also experience urination and defecation as they would with a seizure. The etiology in this situation generally can be traced to orthostatic hypertension. Ask the patient to stay in a sitting position and try to replicate the symptoms.

Situational syncope may be caused by a heart murmur and becomes apparent after exercise. An echocardiogram can be done to assess cardiac symptoms in this case.

Disequilibrium may cause dizziness in as many as 20% of all cases but it is often underestimated and undiagnosed, said Dr. Achar. "Older patients often do not tell the physician that this happens only when they walk," he explained. "Imbalance is the key problem and can be best measured by watching the patient's gait. Older patients may have dizziness due to disequilibrium as a side effect of medications, poor eyesight because of cataracts, and/or Parkinson's disease, he said. Cataract-related dizziness is best diagnosed by dimming the lights and asking the patient to walk.

If the patient has disequilibrium, Dr. Achar recommended the use of simple balance training.
"Using a balance board for 10 minutes 3 times a week can eliminate the dizziness and can reduce the risk of falls and hip fractures in the elderly as well," he noted.

Vertigo is the most common cause of dizziness, said Dr. Achar. The symptoms are any illusion of motion. Patients may describe it as spinning, whirling, tilting, or moving. BPPV is the most common type of vertigo. Meniere's disease is a more serious cause of vertigo. If the patient has any signs of hearing loss, an otolaryngologist should perform an evaluation.

Although it is benign and episodic, BPPV can be quite debilitating, said Dr. Achar. The anatomy of BPPV is the presence of ear rocks in the ear canal that knock fluid around the hair cells, he explained. It is the same phenomenon that occurs after riding a fast circular ride at the amusement park but the fluid doesn't stop moving around so the symptoms come and go. Look at the patient history for episodic dizziness and dizziness that occurs when the patient's head moves as a tell-tale sign.

Dr. Achar described several exercises to use to stabilize movement in the ear and stop BPPV. Generally they involve having the patient lie down and sit up in various positions for short periods of time. One is called the Epley maneuver and was designed by a physician at Northwestern University in Chicago. Dr. Achar urged physicians to view the Northwestern University Web site for more detailed illustrations of this technique. Another option is the Brandt-Daroff exercise, he noted. Keep patients under observation for 10 to 15 minutes after these exercises and ask them to get a ride home if possible. "You want to avoid provoking head positions that might make the BPPV recur," he said.

"If simple in-office maneuvers do not work, send the patient to the ENT who has other treatment alternatives including vibration assistance devices," said Dr. Achar.

"I see a lot of dizziness in my urgent care practice," said Amy Maroldo, MD, a family practice physician in Colorado Springs, Colorado. "Because I only have a 15-minute window to diagnose the patient and don't get follow-up information, I often worry that I may have missed something in my diagnosis." Dr. Maroldo said the information in the workshop gave her more confidence.

Elizabeth Philippe, MD, a family practice physician at a large community health center in South Dade County, Florida, said it is often difficult for her patients to describe their symptoms due to illiteracy and language barriers; many of her patients are immigrants from Haiti. Knowing how to direct the conversation with her patients will help her make a more accurate diagnosis, she said.

AAFP 2006 Annual Scientific Assembly: Procedures Lecture: Office Approach to Diagnosis and Treatment of the Dizzy Patient. Presented September 28, 2006.


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