Diagnostic Approach to Dizziness
Listen
Watch
Show notes:
Dizziness alone accounts for about 5% of all primary care office visits in the US.
5%! That's a huge number.
But as a chief complaint, dizziness is somewhat nebulous.
The causes of dizziness can run the gamut — from annoying-but-benign to yikes-let's-get-you-to-the-ER.
So how do you sift through all the possibilities and uncover what’s :::really going on::: with your patient?
Diagnosing Dizziness in Primary Care
In Diagnostic Approach to Dizziness, we walk NPs through the basics of assessing patients who are experiencing dizziness. We talk about:
✅ The four buckets of ideologies that your patient’s dizziness might fall into
✅ The critical patient history questions. (And why it's important to drill down on what patients mean when they say they're CONSTANTLY dizzy.)
✅ The diagnostic steps and key physical tests to run (and how to do them in a not-scary way for your patients!)
🚩And the red flags you absolutely need to watch out for
-
WEBVTT
1
00:00:08.640 --> 00:00:12.780
Hey there, welcome to the Real World NP podcast.
2
00:00:13.140 --> 00:00:20.400
I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
3
00:00:20.400 --> 00:00:23.140
company for nurse practitioners in primary care.
4
00:00:24.560 --> 00:00:29.420
I'm on a mission to equip and guide new nurse practitioners so that they can feel
5
00:00:30.000 --> 00:00:33.020
capable and take the best care of their patients.
6
00:00:33.600 --> 00:00:37.580
If you're looking for clinical pearls and practice tips without the fluff,
7
00:00:37.660 --> 00:00:39.080
you're in the right place.
8
00:00:39.240 --> 00:00:43.000
Make sure you subscribe and leave a review so you won't miss an episode.
9
00:00:43.280 --> 00:00:46.820
Plus, you'll find links to all the episodes with extra goodies
10
00:00:46.820 --> 00:00:50.420
over at realworldnp.com slash podcast.
11
00:00:55.860 --> 00:00:59.700
In this week's episode, I'm going to be talking to you about dizziness
12
00:00:59.700 --> 00:01:01.800
and the diagnostic approach.
13
00:01:01.900 --> 00:01:06.840
It is a really challenging chief complaint and you are not alone if you're feeling stressed
14
00:01:06.840 --> 00:01:11.320
about it because it stresses out both newer clinicians and experienced clinicians.
15
00:01:11.760 --> 00:01:17.020
And the moral of the story there is that it is one chief complaint, but it has a very
16
00:01:17.020 --> 00:01:23.420
widespread differential diagnosis and the ramifications are, you know, on the range of
17
00:01:23.420 --> 00:01:28.200
very irritating and frustrating for a patient, but ultimately medically benign
18
00:01:28.200 --> 00:01:29.780
to life-threatening.
19
00:01:30.420 --> 00:01:33.140
So it makes sense if it's stressing you out.
20
00:01:33.360 --> 00:01:39.400
So in this episode, I really want to focus on the very high level first approach to
21
00:01:40.480 --> 00:01:41.040
diagnosis.
22
00:01:41.500 --> 00:01:45.820
And I just have to say I talked about this in a couple of different episodes so far,
23
00:01:45.820 --> 00:01:51.700
but when it comes to my approach to my own learning and also teaching is that I have
24
00:01:51.700 --> 00:01:57.440
like a chunk of like the first things we need to know and it kind of compartmentalizes
25
00:01:57.440 --> 00:02:02.160
this is the must-know, let's memorize this, let's, you know, let's bring it up to this
26
00:02:02.160 --> 00:02:02.640
point.
27
00:02:02.860 --> 00:02:06.600
And then once we reach that point, there's multiple different doorways of what paths
28
00:02:06.600 --> 00:02:08.120
we go from there, right?
29
00:02:08.120 --> 00:02:12.780
So that's especially pertinent for dizziness because there's four general buckets of
30
00:02:12.780 --> 00:02:13.440
etiologies.
31
00:02:13.460 --> 00:02:17.360
And once you kind of get to that place, you're leaning towards one or the other,
32
00:02:17.520 --> 00:02:19.960
you can pursue the next path down.
33
00:02:20.120 --> 00:02:21.160
So I want to talk about those.
34
00:02:21.160 --> 00:02:25.920
I want to talk about the general buckets of etiologies, the really important history
35
00:02:25.920 --> 00:02:31.340
questions, and then some of the diagnostic things we can do to help.
36
00:02:31.420 --> 00:02:35.720
And again, this is not comprehensive because this is a huge topic, but this is the initial
37
00:02:35.720 --> 00:02:38.000
approach to hopefully help you feel less uncomfortable.
38
00:02:38.340 --> 00:02:41.380
So when it comes to dizziness, there's four main buckets of etiology.
39
00:02:41.700 --> 00:02:46.840
So one is neurologic, like the underlying source is a neurologic problem.
40
00:02:47.540 --> 00:02:49.680
The second one is cardiac.
41
00:02:50.420 --> 00:02:53.900
So these two are the kind of like most dangerous, right?
42
00:02:53.900 --> 00:02:59.560
The third one is more of a vestibular issue, like an inner ear issue, disequilibrium.
43
00:03:00.000 --> 00:03:00.980
That's like the third one.
44
00:03:01.000 --> 00:03:02.020
Getting into that, hold that thought.
45
00:03:02.500 --> 00:03:08.760
And then the last one is more of a general lightheadedness catch-all last category,
46
00:03:08.940 --> 00:03:14.340
which has some very significant differential diagnoses, but is also the most vague.
47
00:03:14.880 --> 00:03:15.700
So anyway, hold that thought.
48
00:03:15.900 --> 00:03:18.660
So those are the four main buckets of etiologies.
49
00:03:18.960 --> 00:03:22.780
So this frames the way that I approach my history taking
50
00:03:22.780 --> 00:03:24.100
with those things in mind.
51
00:03:24.140 --> 00:03:28.560
Even if I can't rattle off what the differential diagnoses are in that neurologic category,
52
00:03:28.980 --> 00:03:30.840
I know that's where I'm starting, right?
53
00:03:30.840 --> 00:03:33.420
And I'm kind of like pulling through the history questions
54
00:03:33.420 --> 00:03:36.680
as well as a physical exam to help me point in a direction or not.
55
00:03:36.880 --> 00:03:42.080
So on that thought of those four buckets, there's kind of four presentations as well.
56
00:03:43.060 --> 00:03:48.780
So there is vertigo, like vertiginous dizziness, which is more of a spinning,
57
00:03:48.960 --> 00:03:51.680
either spinning of themselves, spinning of the room.
58
00:03:51.680 --> 00:03:56.840
As a person who's experienced vertigo, it is very difficult for patients to differentiate.
59
00:03:57.760 --> 00:04:01.980
But you can try to ask whether it's them or if it's the room.
60
00:04:02.140 --> 00:04:08.240
But there's vertiginous, there's lightheadedness, there's disequilibrium,
61
00:04:08.580 --> 00:04:10.080
and then there's presyncope.
62
00:04:10.460 --> 00:04:11.700
I should have put that in the same order.
63
00:04:11.820 --> 00:04:15.460
But basically, you're trying to elicit from the person.
64
00:04:16.100 --> 00:04:17.540
What does it feel like?
65
00:04:17.800 --> 00:04:19.899
That's the first, aside from knowing those four buckets,
66
00:04:20.420 --> 00:04:23.980
the person you're trying to get them to tell you how they would describe it.
67
00:04:24.120 --> 00:04:27.900
And does it fall into that category of spinning, lightheadedness,
68
00:04:28.100 --> 00:04:30.020
presyncope, or near fainting?
69
00:04:30.240 --> 00:04:31.720
Or is it a general lightheadedness?
70
00:04:31.740 --> 00:04:35.060
Because that kind of correlates with those four buckets of etiologies as well.
71
00:04:35.300 --> 00:04:39.060
One disclaimer, though, is that for the real world, it is difficult.
72
00:04:39.860 --> 00:04:41.800
I speak English as my native language.
73
00:04:42.000 --> 00:04:45.180
And I have patients who both speak native English
74
00:04:45.180 --> 00:04:47.460
and also many, many, many other languages.
75
00:04:47.460 --> 00:04:51.440
And the nuances of language are different throughout cultures, right?
76
00:04:51.660 --> 00:04:56.680
So I don't feel like 100% anecdotally speaking that this is super helpful.
77
00:04:56.720 --> 00:04:59.720
I can ask patients all day how they describe their symptoms.
78
00:04:59.880 --> 00:05:02.260
But it may or may not translate
79
00:05:02.820 --> 00:05:07.100
in the way that culturally I'm coming from as an English-speaking person.
80
00:05:07.920 --> 00:05:11.600
So anyway, theoretically, if the person can tell you
81
00:05:11.600 --> 00:05:15.280
versus you leading them with information, that's what we're supposed to do.
82
00:05:15.280 --> 00:05:18.500
You can kind of tell if it's more of a spinning or a lightheadedness
83
00:05:18.500 --> 00:05:22.500
or near fainting or kind of disequilibrium experience.
84
00:05:23.500 --> 00:05:27.880
So from there, again, this is the same thing for every chief complaint.
85
00:05:28.160 --> 00:05:29.860
Asking all of your questions from old cart,
86
00:05:30.000 --> 00:05:33.120
onset, location, duration, characteristics, et cetera.
87
00:05:33.720 --> 00:05:36.700
As well as asking the pertinent ROS questions
88
00:05:36.700 --> 00:05:38.700
for whatever body system you're talking about.
89
00:05:38.800 --> 00:05:39.580
Again, that is the hack.
90
00:05:39.700 --> 00:05:43.300
That's the quick hack of like, oh, it's neurologic and cardiac
91
00:05:43.300 --> 00:05:44.820
are the top two ones to be concerned about.
92
00:05:44.820 --> 00:05:46.040
I'm just going to ask all those questions.
93
00:05:46.120 --> 00:05:48.140
And literally, that's all I do, right?
94
00:05:48.200 --> 00:05:49.220
Every single time.
95
00:05:49.760 --> 00:05:53.760
Chest pain, palpitations, near syncope, actual syncope,
96
00:05:54.580 --> 00:05:57.300
like edema, all of these things, like asking the full cardiac.
97
00:05:58.260 --> 00:05:59.320
Neurologic, same thing.
98
00:05:59.400 --> 00:06:04.140
So do they have ataxia, diplopia, trouble with their balance,
99
00:06:04.460 --> 00:06:05.620
speech, like all these different things,
100
00:06:05.620 --> 00:06:09.140
like asking that full ROS to kind of help guide you.
101
00:06:09.180 --> 00:06:11.740
As it relates to that more disequilibrium,
102
00:06:11.860 --> 00:06:14.500
but perhaps the inner ear related issues,
103
00:06:14.820 --> 00:06:19.140
those differential diagnoses include like BPPV and Meniere's.
104
00:06:19.140 --> 00:06:21.700
I have specific ROS questions that I ask for that.
105
00:06:21.880 --> 00:06:24.100
Again, you can ask all of the ear related questions
106
00:06:24.100 --> 00:06:25.900
because you can also have that sensation
107
00:06:25.900 --> 00:06:28.220
with ear infections, for example,
108
00:06:28.220 --> 00:06:29.460
like a lot of different things.
109
00:06:29.720 --> 00:06:31.840
So you could ask all of the ear questions,
110
00:06:32.140 --> 00:06:35.260
but specifically hearing loss, tinnitus,
111
00:06:35.960 --> 00:06:37.780
and I think that's the main one.
112
00:06:38.080 --> 00:06:40.320
Oh, and then the other thing is about like,
113
00:06:40.360 --> 00:06:42.040
you've already asked the questions with old cart
114
00:06:42.040 --> 00:06:43.420
of like what makes it better or worse,
115
00:06:43.420 --> 00:06:45.640
but position makes a difference as well,
116
00:06:45.660 --> 00:06:48.320
like what triggers it in terms of position changes,
117
00:06:48.660 --> 00:06:51.580
turning head, turning their head, turning over in bed,
118
00:06:51.680 --> 00:06:54.220
standing up from laying down to sitting up,
119
00:06:54.240 --> 00:06:56.360
like is it causing like a lightheadedness,
120
00:06:56.420 --> 00:06:58.540
like a visual darkness, like nearly passing out,
121
00:06:58.540 --> 00:06:59.460
like that kind of stuff.
122
00:06:59.760 --> 00:07:02.060
So that's further information there.
123
00:07:02.560 --> 00:07:06.080
So that's the general like first like historical approach.
124
00:07:06.700 --> 00:07:09.840
One other thing I guess I want to add about lightheadedness
125
00:07:09.840 --> 00:07:13.180
is that lightheadedness is very non-specific.
126
00:07:13.180 --> 00:07:15.440
So this could be psychologic, right?
127
00:07:16.940 --> 00:07:20.180
Anxiety-related, I never want to blame something
128
00:07:20.180 --> 00:07:21.900
on something anxiety-related
129
00:07:21.900 --> 00:07:24.960
until we've done our full medical workup, right?
130
00:07:24.960 --> 00:07:26.780
I see a lot of people being dismissive with dizziness,
131
00:07:26.780 --> 00:07:28.100
so I just want to add that in there.
132
00:07:28.440 --> 00:07:31.280
But lightheadedness that's kind of vague and it's there,
133
00:07:31.460 --> 00:07:33.920
you want to ask things about any medications
134
00:07:33.920 --> 00:07:35.860
they're taking, elderly patients,
135
00:07:36.000 --> 00:07:38.560
you want to consider kind of like occult infections,
136
00:07:38.700 --> 00:07:40.540
like a UTI, something like that.
137
00:07:40.540 --> 00:07:43.500
You want to be a little bit more like zoomed out
138
00:07:43.500 --> 00:07:44.540
when it comes to lightheadedness
139
00:07:44.540 --> 00:07:46.140
in terms of their full clinical picture,
140
00:07:46.160 --> 00:07:47.440
like do they have kidney disease,
141
00:07:47.500 --> 00:07:48.360
do they have liver disease,
142
00:07:48.400 --> 00:07:50.900
like what other things might be a kind of like
143
00:07:50.900 --> 00:07:52.900
a vague lightheadedness, a symptom of
144
00:07:52.900 --> 00:07:55.080
in the context of their risk factors
145
00:07:55.080 --> 00:07:56.620
and their underlying conditions.
146
00:07:56.860 --> 00:07:59.260
And I think one other tricky thing about history
147
00:07:59.260 --> 00:08:02.140
is patients come in all the time saying
148
00:08:02.140 --> 00:08:03.800
that I have dizziness constantly.
149
00:08:03.860 --> 00:08:05.260
And what's really important,
150
00:08:05.260 --> 00:08:06.600
especially as a newer clinician,
151
00:08:06.680 --> 00:08:08.660
is to really drill down what that means
152
00:08:08.660 --> 00:08:11.580
because are you talking about episodic,
153
00:08:11.640 --> 00:08:13.580
like BPPV for example,
154
00:08:13.980 --> 00:08:17.100
they have constant, quote unquote constant symptoms,
155
00:08:17.120 --> 00:08:18.640
but it's constant episodes
156
00:08:18.640 --> 00:08:20.320
that doesn't last constantly.
157
00:08:20.780 --> 00:08:22.080
So is it intermittent?
158
00:08:22.660 --> 00:08:25.440
Is it seconds, minutes, hours?
159
00:08:26.120 --> 00:08:27.900
And how long does that last for?
160
00:08:28.260 --> 00:08:29.300
How often does it occur?
161
00:08:29.360 --> 00:08:31.440
Things like that, like really drilling into that.
162
00:08:31.700 --> 00:08:34.059
Before I pop into the physical exam,
163
00:08:34.080 --> 00:08:36.200
I want to talk about the red flags.
164
00:08:36.480 --> 00:08:38.520
So I've talked about some of them so far,
165
00:08:38.520 --> 00:08:41.480
but if you have patients with things like ataxia,
166
00:08:42.460 --> 00:08:43.299
severe headache,
167
00:08:44.280 --> 00:08:46.620
severe symptoms that are actually constant
168
00:08:46.620 --> 00:08:47.720
for more than an hour,
169
00:08:48.040 --> 00:08:49.980
any actual loss of consciousness,
170
00:08:50.640 --> 00:08:52.040
or neurologic deficits.
171
00:08:52.120 --> 00:08:53.800
Again, this is a little bit more on the exam part
172
00:08:53.800 --> 00:08:54.540
than the history,
173
00:08:54.740 --> 00:08:56.920
but if they tell you about neurologic deficits,
174
00:08:57.180 --> 00:08:58.520
those are all red flags.
175
00:08:58.540 --> 00:09:01.160
Those are certainly core red flags to watch out for.
176
00:09:02.040 --> 00:09:04.060
Tag in your colleagues and your supervisor.
177
00:09:04.200 --> 00:09:06.060
I definitely recommend if you are a newer clinician.
178
00:09:06.060 --> 00:09:09.560
I basically always run dizziness by a colleague,
179
00:09:09.880 --> 00:09:11.440
especially if it's not clear to me.
180
00:09:11.580 --> 00:09:12.980
Like if it's not crystal clear,
181
00:09:13.120 --> 00:09:14.340
exactly what we're dealing with,
182
00:09:14.340 --> 00:09:16.620
or if they have any medical comorbidities complexities,
183
00:09:16.780 --> 00:09:18.180
it gets more complex.
184
00:09:18.400 --> 00:09:21.340
And there are many different options involved there.
185
00:09:21.480 --> 00:09:22.240
But at the very least,
186
00:09:22.240 --> 00:09:25.060
we can start with that really solid history.
187
00:09:25.220 --> 00:09:27.740
Okay, so I want to wrap up this with
188
00:09:27.740 --> 00:09:29.980
what are the kind of like physical exams
189
00:09:29.980 --> 00:09:31.520
that are going to help you, again,
190
00:09:31.840 --> 00:09:33.880
even further bolster your history.
191
00:09:33.880 --> 00:09:36.440
So the physical exams we always want to do
192
00:09:36.440 --> 00:09:38.020
is a full neurologic exam.
193
00:09:39.240 --> 00:09:41.260
So all the cranial nerves as best we can,
194
00:09:41.420 --> 00:09:42.820
I usually skip the smell one,
195
00:09:43.860 --> 00:09:46.060
but kind of getting a good practice of that.
196
00:09:46.060 --> 00:09:47.740
Not necessarily the DTRs,
197
00:09:47.740 --> 00:09:48.820
the deep tendon reflexes,
198
00:09:48.820 --> 00:09:51.220
but like what is a full neurologic exam?
199
00:09:51.240 --> 00:09:53.860
And are you comfortable that you've assessed that, right?
200
00:09:54.060 --> 00:09:57.320
Do they have any vertical nystagmus, for example?
201
00:09:57.360 --> 00:09:58.260
That is a red flag.
202
00:09:59.120 --> 00:10:01.020
So doing that full neurologic exam,
203
00:10:01.580 --> 00:10:02.720
the other one to include,
204
00:10:02.720 --> 00:10:04.400
it's really important is a Romberg test,
205
00:10:04.540 --> 00:10:06.460
which is part of the general neuro exam,
206
00:10:06.460 --> 00:10:08.360
but we don't necessarily do that every time.
207
00:10:08.600 --> 00:10:10.180
But a Romberg test can really help
208
00:10:10.180 --> 00:10:13.040
to see if there is any signs of dysequilibrium.
209
00:10:13.140 --> 00:10:14.340
You want to assess their gait
210
00:10:14.340 --> 00:10:16.920
and see if you're noticing a gait disturbance, right?
211
00:10:16.920 --> 00:10:18.600
Because again, if there is a taxia,
212
00:10:18.600 --> 00:10:19.360
we want to think about
213
00:10:19.360 --> 00:10:21.340
are there neurologic urgencies
214
00:10:21.340 --> 00:10:22.420
or emergencies going on,
215
00:10:22.440 --> 00:10:23.420
like a stroke or something.
216
00:10:23.620 --> 00:10:25.820
The next one is a Dix-Hallpike maneuver,
217
00:10:25.880 --> 00:10:28.420
especially if they have symptoms of that ear,
218
00:10:28.900 --> 00:10:31.920
ear-related or vertiginous dizziness.
219
00:10:31.920 --> 00:10:33.860
But one of the things that's frustrating
220
00:10:33.860 --> 00:10:34.720
with the Dix-Hallpike,
221
00:10:34.760 --> 00:10:36.360
so I can link to a video down below
222
00:10:36.360 --> 00:10:38.020
for a nice demonstration of it.
223
00:10:38.280 --> 00:10:39.540
Most patients who are dizzy
224
00:10:39.540 --> 00:10:41.000
do not want you to do this,
225
00:10:41.080 --> 00:10:42.780
my anecdotal experience.
226
00:10:43.300 --> 00:10:44.920
And as a patient myself,
227
00:10:44.920 --> 00:10:47.740
it is a little terrifying to basically trust fall
228
00:10:47.740 --> 00:10:48.580
with your provider,
229
00:10:48.880 --> 00:10:50.420
if you especially feel like you're just meeting them.
230
00:10:50.700 --> 00:10:53.100
So one of the things that I recommend
231
00:10:53.100 --> 00:10:54.480
is that when you have patients,
232
00:10:54.520 --> 00:10:55.540
and again, the video is down below
233
00:10:55.540 --> 00:10:56.680
if you haven't seen this before,
234
00:10:57.060 --> 00:10:59.260
is having patients lay on their back
235
00:10:59.260 --> 00:11:00.260
with their knees up,
236
00:11:00.260 --> 00:11:02.020
going to a seated position,
237
00:11:03.000 --> 00:11:05.180
you're supposed to hold the patient's head to the side
238
00:11:05.180 --> 00:11:07.100
and basically drop them quickly
239
00:11:07.100 --> 00:11:09.560
so their head is hanging off the edge of the table.
240
00:11:09.960 --> 00:11:12.420
And maybe your exam room is not even set up for that,
241
00:11:12.420 --> 00:11:13.680
which is the case in my clinic.
242
00:11:14.580 --> 00:11:16.000
So two things I do for that.
243
00:11:16.140 --> 00:11:18.160
So one is I put my hand behind their head
244
00:11:18.160 --> 00:11:21.120
and then I also put my hand very solidly
245
00:11:21.120 --> 00:11:22.280
in the middle of their back.
246
00:11:22.440 --> 00:11:24.940
So they feel supported in two different places.
247
00:11:25.140 --> 00:11:26.260
They have their knees up.
248
00:11:26.260 --> 00:11:28.200
It's less of like a stressed out
249
00:11:28.200 --> 00:11:29.800
type of falling situation.
250
00:11:29.800 --> 00:11:31.440
And then if I have a pillow,
251
00:11:32.120 --> 00:11:33.920
basically the main thing with the Dix Hall Pike
252
00:11:33.920 --> 00:11:34.780
is that your head,
253
00:11:34.900 --> 00:11:37.220
the patient's head has to be like hanging over.
254
00:11:37.440 --> 00:11:38.420
So if you have a pillow
255
00:11:38.420 --> 00:11:42.320
where their head is like posteriorly tilted
256
00:11:42.320 --> 00:11:44.620
basically off to the side and tilted down
257
00:11:44.620 --> 00:11:46.100
because it's draping over a pillow
258
00:11:46.100 --> 00:11:47.360
instead of the edge of the table,
259
00:11:47.580 --> 00:11:49.120
that potentially can be helpful.
260
00:11:49.380 --> 00:11:51.060
And I just want to say about the Dix Hall Pike
261
00:11:51.060 --> 00:11:53.160
is that what you're looking for is nystagmus,
262
00:11:53.380 --> 00:11:54.160
horizontal nystagmus.
263
00:11:54.240 --> 00:11:55.940
Again, vertical nystagmus is very concerning.
264
00:11:56.040 --> 00:11:59.100
So seek further care for that patient if they have that.
265
00:11:59.100 --> 00:12:01.580
But you're basically looking for 30 seconds
266
00:12:01.580 --> 00:12:03.600
to see if they have horizontal nystagmus,
267
00:12:03.660 --> 00:12:06.040
putting them back up again and holding for 30 seconds,
268
00:12:06.040 --> 00:12:07.540
watching again for nystagmus.
269
00:12:08.040 --> 00:12:09.460
Any test that we have
270
00:12:09.460 --> 00:12:11.680
has its own sensitivity and specificity.
271
00:12:11.880 --> 00:12:13.360
So if you have patients who have symptoms
272
00:12:13.360 --> 00:12:14.540
and don't have nystagmus,
273
00:12:14.840 --> 00:12:17.360
they could still have something like BPPV,
274
00:12:17.380 --> 00:12:19.520
which is what you're assessing for with that test.
275
00:12:19.680 --> 00:12:21.480
The other tests that you want to consider
276
00:12:21.480 --> 00:12:23.360
either exam or test-wise
277
00:12:23.360 --> 00:12:25.980
really depends again on the buckets of etiologies
278
00:12:25.980 --> 00:12:27.120
that you're suspecting.
279
00:12:27.120 --> 00:12:30.500
So does this sound almost like blackening of their vision
280
00:12:30.500 --> 00:12:31.520
when they stand up?
281
00:12:31.620 --> 00:12:34.180
They're feeling very light-headed,
282
00:12:34.300 --> 00:12:35.420
maybe like they might faint,
283
00:12:35.460 --> 00:12:36.960
and they also have CHF.
284
00:12:36.960 --> 00:12:38.620
They're also on diuretics.
285
00:12:38.820 --> 00:12:40.160
Like, what are we thinking?
286
00:12:40.260 --> 00:12:42.020
Is this sounding like a cardiac etiology?
287
00:12:42.540 --> 00:12:44.020
So other tests, in-office tests,
288
00:12:44.020 --> 00:12:45.240
that we can consider doing,
289
00:12:45.360 --> 00:12:46.580
depending on the history,
290
00:12:47.100 --> 00:12:48.720
are orthostatic vital signs,
291
00:12:48.840 --> 00:12:50.060
looking to see if there's a change
292
00:12:50.060 --> 00:12:51.620
in blood pressure and or heart rate.
293
00:12:51.660 --> 00:12:54.860
Again, there's a little zebra diagnosis called POTS,
294
00:12:54.860 --> 00:12:56.800
if you're not familiar with that one, POTS.
295
00:12:56.800 --> 00:12:59.080
Which can cause a heart rate hike
296
00:12:59.080 --> 00:13:00.180
instead of the blood pressure.
297
00:13:00.320 --> 00:13:01.380
But anyway, you can go down
298
00:13:01.380 --> 00:13:03.000
that little rabbit hole if you'd like.
299
00:13:03.940 --> 00:13:05.280
But orthostatic vital signs.
300
00:13:05.360 --> 00:13:06.840
Do you want to consider an EKG?
301
00:13:06.900 --> 00:13:07.960
Because you're thinking that
302
00:13:07.960 --> 00:13:09.760
they're having palpitations and near syncope,
303
00:13:10.640 --> 00:13:11.720
thinking about that.
304
00:13:12.060 --> 00:13:14.940
And then the other pieces are visual, right?
305
00:13:14.940 --> 00:13:16.460
So for the non-specific dizziness,
306
00:13:16.640 --> 00:13:18.100
do they have any visual impairments?
307
00:13:18.140 --> 00:13:19.960
Do they have any hearing impairments?
308
00:13:20.300 --> 00:13:22.160
Which can contribute to that
309
00:13:22.160 --> 00:13:24.360
sense of light-headedness or disequilibrium.
310
00:13:24.780 --> 00:13:26.240
And then the other thing, again,
311
00:13:26.240 --> 00:13:27.920
relating to that underlying,
312
00:13:28.180 --> 00:13:30.400
the generalized non-specific dizziness
313
00:13:30.400 --> 00:13:31.300
that's light-headed.
314
00:13:31.760 --> 00:13:33.460
What are their potential risk factors
315
00:13:33.460 --> 00:13:34.900
in underlying comorbidities?
316
00:13:35.080 --> 00:13:36.580
Do they have a risk for UTI?
317
00:13:36.980 --> 00:13:38.920
Do you want to consider checking a CVC
318
00:13:38.920 --> 00:13:39.640
or a TSH?
319
00:13:39.820 --> 00:13:40.460
Things like that.
320
00:13:40.580 --> 00:13:43.240
What are the potential other medical factors
321
00:13:43.240 --> 00:13:44.880
to consider that might be related
322
00:13:44.880 --> 00:13:46.880
to that non-specific dizziness?
323
00:13:47.260 --> 00:13:48.900
Which I wish that was more helpful,
324
00:13:48.900 --> 00:13:51.520
but that's just the first pass
325
00:13:51.520 --> 00:13:52.640
of how to get here
326
00:13:52.640 --> 00:13:54.780
with this differential diagnosis.
327
00:13:54.780 --> 00:13:56.360
And again, as always,
328
00:13:56.380 --> 00:13:57.780
if you need help with lab interpretation,
329
00:13:58.140 --> 00:13:59.620
definitely join us for the lab crash course,
330
00:13:59.640 --> 00:14:01.880
which will be linked down to this video as well.
331
00:14:02.040 --> 00:14:04.080
But yeah, that's the general approach to dizziness.
332
00:14:04.160 --> 00:14:05.540
So again, just to recap,
333
00:14:05.720 --> 00:14:08.180
it always comes back to the hacked history
334
00:14:08.180 --> 00:14:10.160
of all the old cart questions,
335
00:14:10.300 --> 00:14:12.320
all the ROS questions for your body systems.
336
00:14:12.560 --> 00:14:14.080
And then as you pull in
337
00:14:14.080 --> 00:14:15.820
the differential diagnoses in your mind,
338
00:14:15.840 --> 00:14:17.540
you can ask those more specific questions.
339
00:14:17.560 --> 00:14:20.060
But you can really narrow that down for dizziness,
340
00:14:20.600 --> 00:14:22.280
maybe make a little quick text for yourself,
341
00:14:22.340 --> 00:14:24.060
which is what I did for years and years.
342
00:14:24.060 --> 00:14:26.540
I actually mostly have it in my head now,
343
00:14:26.800 --> 00:14:28.960
but I still use my little quick text
344
00:14:28.960 --> 00:14:31.220
and thinking about the physical exams
345
00:14:31.220 --> 00:14:32.420
that you want to do
346
00:14:32.420 --> 00:14:34.400
and never hesitating to ask for help.
347
00:14:34.540 --> 00:14:36.740
Because again, this is a really tricky chief complaint
348
00:14:36.740 --> 00:14:38.600
that I still run by my colleagues
349
00:14:38.600 --> 00:14:40.120
just to make sure that I'm like,
350
00:14:40.160 --> 00:14:41.580
am I missing anything there?
351
00:14:41.820 --> 00:14:43.280
What do you think about this?
352
00:14:43.480 --> 00:14:44.100
Et cetera, et cetera.
353
00:14:44.380 --> 00:14:46.420
So I hope you enjoyed this episode.
354
00:14:46.480 --> 00:14:47.260
If you have not grabbed
355
00:14:47.260 --> 00:14:49.320
the ultimate resource guide for the new NP,
356
00:14:49.420 --> 00:14:52.000
head over to realworldnp.com slash guide.
357
00:14:52.000 --> 00:14:55.040
You'll find these videos sent straight to your inbox
358
00:14:55.040 --> 00:14:57.740
every week with notes from the patient stories
359
00:14:57.740 --> 00:15:00.440
and bonuses that I really just don't share anywhere else.
360
00:15:00.620 --> 00:15:01.860
Thank you so much for watching.
361
00:15:01.940 --> 00:15:03.200
Hang in there and I'll see you soon.
362
00:15:09.140 --> 00:15:10.680
That's our episode for today.
363
00:15:10.820 --> 00:15:12.580
Thank you so much for listening.
364
00:15:12.960 --> 00:15:15.320
Make sure you subscribe, leave a review
365
00:15:15.320 --> 00:15:17.220
and tell all your NP friends
366
00:15:17.220 --> 00:15:20.180
so together we can help as many nurse practitioners
367
00:15:20.180 --> 00:15:22.940
as possible give the best care to their patients.
368
00:15:23.240 --> 00:15:24.840
If you haven't gotten your copy
369
00:15:24.840 --> 00:15:27.440
of the ultimate resource guide for the new NP,
370
00:15:27.840 --> 00:15:30.940
head over to realworldnp.com slash guide.
371
00:15:31.360 --> 00:15:33.180
You'll get these episodes sent straight
372
00:15:33.180 --> 00:15:35.980
to your inbox every week with notes from me,
373
00:15:36.380 --> 00:15:38.080
patient stories and extra bonuses
374
00:15:38.080 --> 00:15:40.200
I really just don't share anywhere else.
375
00:15:40.620 --> 00:15:42.160
Thank you so much again for listening.
376
00:15:42.320 --> 00:15:43.540
Take care and talk soon.
© 2025 Real World NP. For educational and informational purposes only, see realworldnp.com/disclaimer for full details.
