Transcript: Diagnostic Approach to Dizziness

Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP. You are watching NP practice made simple the weekly videos to help save you time, frustration and help you learn faster so you can take the best care of your patients.

In this week's episode, I'm going to be talking to you about dizziness and the diagnostic approach. It is a really challenging chief complaint and you are not alone if you're feeling stressed about it because it stresses out both newer clinicians and experienced clinicians. And the moral of the story there is that it is one chief complaint, but it has a very widespread differential diagnosis. And the ramifications are on the range of very irritating and frustrating for a patient, but ultimately medically benign to life threatening. So it makes sense if it's stressing you out. So in this episode, I really want to focus on the very high level first approach to diagnosis.

And I just have to say, I talked about this in a couple of different episodes so far, but when it comes to my approach to my own learning and also teaching is that I have a chunk of the first things we need to know and it kind of compartmentalizes, this is the must know, let's memorize this, let's bring it up to this point. And then once we reach that point, there's multiple different doorways of what paths we go from there. Right? So that's especially pertinent for dizziness because there's four general buckets of etiologies. And once you kind of get to that place, you're leaning towards one or the other, you can pursue the next path down. So I want to talk about those. I want to talk about the general buckets of etiologies, the really important history questions, and then some of the diagnostic things we can do to help. And again, this is not comprehensive because this is a huge topic, but this is the initial approach to hopefully help you feel less uncomfortable.

So when it comes to dizziness, there's four main buckets of etiology. So one is neurologic, the underlying source is a neurologic problem. The second one is cardiac. So these two are the kind of most dangerous. The third one is more of a vestibular issue, like an inner ear issue, disequilibrium. That's a third one. Get into that. Hold that thought. And then the last one is more of a general lightheadedness, catch-all last category, which has some very significant differential diagnoses, but is also the most vague. So anyway, hold that thought. So those are the four main buckets of etiologies. So this frames the way that I approach my history taking. With those things in mind, even if I can't rattle off what the differential diagnoses are in that neurologic category, I know that's where I'm starting and I'm kind of pulling through the history questions as well as a physical exam to help me point in a direction or not.

So on that thought of those four buckets, there's kind of four presentations as well. So there is vertigo, like vertiginous dizziness, which is more of a spinning, either spinning of themselves, spinning of the room. As a person who's experienced vertigo, it is very difficult for patients to differentiate, but you can try to ask whether it's them or if it's the room. But there's vertiginous, there's lightheadedness, there's disequilibrium, and then there's presyncope. I should have put that in the same order. But basically you're trying to elicit from the person, what does it feel like? Aside from knowing those four buckets, the person, you're trying to get them to tell you how they would describe it. And does it fall into that category of spinning, lightheadedness, presyncope or near fainting, or is a general lightheadedness? Because that kind of correlates with those four buckets of ideologies as well.

One disclaimer though is that for the real world, it is difficult. I speak English as my native language and I have patients who both speak native English and also many, many, many other languages. And the nuances of language are different throughout cultures. So I don't feel like a hundred percent, anecdotally speaking, that this is super helpful. I can ask patients all day how they describe their symptoms, but it may or may not translate in the way that culturally I'm coming from as an English speaking person.

So anyway, theoretically if the person can tell you versus you leading them with information, that's what we're supposed to do. You can kind of tell if it's more of a spinning or a lightheadedness or near fainting or kind of disequilibrium experience. So from there, again, this is the same thing for every chief complaint, asking all of your questions from old cart, onset, location, duration, characteristics, et cetera, as well as asking the pertinent ROS questions for whatever body system you're talking about. Again, that is the hack, that's the quick hack of like, "Oh, it's neurologic and cardiac are the top two ones to be concerned about. I'm just going to ask all those questions". And literally that's all I do every single time.

Chest pain, palpitations, near-syncope, actual syncope, edema, all of these things. Asking the full cardiac, neurologic, same thing. So do they have ataxia, diplopia, trouble with their balance, speech, all these different things, asking that full ROS to help guide you. As it relates to that more dysequilibrium, but perhaps the inner ear related issues, those differential diagnoses include BPPV and Meneire's. I have specific ROS questions that I ask for that. Again, you can ask all of the ear related questions because you can also have that sensation with ear infections, for example. A lot of different things. So you could ask all of the ear questions, but specifically hearing loss, tinnitus, and I think that's the main one.

Oh, and then the other thing is about, you've already asked the questions with the old card of what makes it better or worse, but position makes a difference as well. What triggers it in terms of position changes, turning their head, turning over in bed, standing up from laying down to sitting up, is it causing a lightheadedness, a visual darkness, nearly passing out, that kind of stuff? So that's further information there. So that's the general first historical approach.

One other thing I guess I want to add about lightheadedness is that lightheadedness is very non-specific. So this could be psychologic, anxiety related. I never want to blame something on something anxiety related until we've done our full medical workup. I see a lot of people being dismissive with dizziness. So I just want to add that in there. But lightheadedness, that's kind of vague and it's there, you want to ask things about any medications they're taking. Elderly patients, you want to consider kind of occult infections like a UTI, something like that. You want to be a little bit more zoomed out when it comes to lightheadedness in terms of their full clinical picture. Do they have kidney disease, do they have liver disease? What other things might be a kind of a vague lightheadedness a symptom of, in the context of their risk factors and their underlying conditions.

And I think one other tricky thing about history is patients come in all the time saying that I have dizziness constantly. And what's really important, especially as a newer clinician, is to really drill down what that means. Because are you talking about episodic? Like BPPV for example, they have constant, "constant" symptoms, but it's constant episodes that doesn't last constantly. So is it intermittent? Is it seconds, minutes, hours? And how long does it last for? How often does it occur? Things like that. Really drilling into that.

Before I pop into the physical exam, I want to talk about the red flags. So I've talked about some of them so far, but if you have patients with things like ataxia, severe headache, severe symptoms that are actually constant for more than an hour, any actual loss of consciousness or neurologic deficits, again, this is a little bit more on the exam part than the history, but if they tell you about neurologic deficits, those are all red flags. Those are certainly core red flags to watch out for. Tag in your colleagues and your supervisor, I definitely recommend if you are a newer clinician. I basically always run dizziness by a colleague, especially if it's not clear to me. If it's not crystal clear exactly what we're dealing with or if they have any medical comorbidities complexities, it gets more complex and there are many different options involved there. But at the very least we can start with that really solid history.

Okay. So I want to wrap up this with what are the physical exams that are going to help you, again, even further bolster your history? So the physical exams we always want to do is a full neurologic exam. So all the cranial nerves as best we can. I usually skip the smell one, but kind of getting a good practice of that. Not necessarily the DTRs, the deep tendon reflexes, but what is a full neurologic exam and are you comfortable that you've assessed that, right? Do they have any vertical nystagmus, for example? That is a red flag. So doing that full neurologic exam.

The other one to include that's really important is a Romberg Test, which is part of the general neuro exam, but we don't necessarily do that every time. But a Romberg Test can really help to see if there is any signs of dysequilibrium. You want to assess their gait and see if you're noticing a gait disturbance, right? Because again, if there is ataxia, we want to think about, are there neurologic urgencies or emergencies going on like a stroke or something?

The next one is a Dix-Hallpike maneuver, especially if they have symptoms of that ear related or vertiginous dizziness. But one of the things that's frustrating with the Dix-Hallpike, so I can link to a video down below for a nice demonstration of it, most patients who are dizzy do not want you to do this, in my anecdotal experience. And as a patient myself, it is a little terrifying to basically trust fall with your provider, especially if you're just meeting them. So one of the things that I recommend is that when you have patients, and again, the videos down below if you haven't seen this before, is having patients lay on their back with their knees up, going to a seated position, you're supposed to hold the patient's head to the side and basically drop them quickly so their head is hanging off the edge of the table and maybe your exam room is not even set up for that, which is the case in my clinic.

So two things I do for that. So one is I put my hand behind their head and then I also put a hand very solidly in the middle of their back so they feel supported in two different places, they have their knees up, it's less of a stressed out type of falling situation. And then if I have a pillow. But basically the main thing with the Dix-Hallpike is that the patient's head has to be hanging over. So if you have a pillow where their head is posteriorly tilted basically, off to the side and tilted down because it's draping over a pillow instead of the edge of the table, that potentially can be helpful. And I just want to say about the Dix-Hallpike is that what you're looking for is nystagmus, horizontal nystagmus. Again, vertical nystagmus is very concerning, so seek further care for that patient if they have that.

But you're basically looking for 30 seconds to see if they have horizontal nystagmus, putting them back up again and holding for 30 seconds, watching again for nystagmus. Any test that we have has its own sensitivity and specificity. So if you have patients who have symptoms and don't have nystagmus, they could still have something like BPPV, which is what you're assessing for with that test.

The other tests that you want to consider either exam or test-wise really depends again on the buckets of etiologies that you're suspecting. So does this sound like a almost blackening of their vision when they stand up, they're feeling very lightheaded, like maybe they might faint, and they also have CHF, they're also on diuretics? What are we thinking? Is this sounding like a cardiac etiology? So other tests, in-office tests that we can consider doing depending on the history are orthostatic vital signs, looking to see if there's a change in blood pressure and or heart rate. Again, there's a little zebra diagnosis called POTS, if you're not familiar with that one, P-O-T-S, which can cause a heart rate hike instead of the blood pressure. But anyway, you can go down that little rabbit hole if you'd like. But orthostatic vital signs, do you want to consider an EKG because you're thinking that they're having palpitations and near-syncope, right? Thinking about that.

And then the other pieces are visual, right? So for the non-specific dizziness, do they have any visual impairments? Do they have any hearing impairments which can contribute to that sense of lightheadedness or dysequilibrium? And then the other thing, again, relating to the generalized non-specific dizziness that's lightheaded, what are their potential risk factors and underlying comorbidities? Do they have a risk for UTI? Do you want to consider checking a CBC or a TSH? Things like that. What are the potential other medical factors to consider that might be related to that non-specific dizziness? Which I wish that was more helpful, but that's just the first path of how to get here with this differential diagnosis. And again, as always, if you need help with lab interpretation, definitely join us for the lab crash course, which will be linked down below this video as well. But yeah, that's the general approach to dizziness.

So again, just to recap, it always comes back to the hacked history of all the old cart questions, all the ROS questions for your body systems. And then as you pull in the differential diagnoses in your mind, you can ask those more specific questions, but you can really narrow that down for dizziness. Maybe make a little quick text for yourself, which is what I did for years and years, and I actually mostly have it in my head now, but I still use my little quick text. And thinking about the physical exams that you want to do and never hesitating to ask for help because again, this is a really tricky chief complaint that I still run by my colleagues just to make sure that I'm like, "Am I missing anything there? What do you think about this?" Et cetera, et cetera.

So I hope you enjoyed this episode. If you have not grabbed the ultimate resource guide for the new NP, head over to realworldnp.com/guide. You'll find these videos sent straight to your inbox every week with notes from me, and patient stories and bonuses that I really just don't share anywhere else. Thank you so much for watching. Hang in there and I'll see you soon.