医学部生の自習室

医学部生の自習室/Med student's study room

医学生の学びを世界へ / From Japan to the World: Daily Stories of a Medical Student

問診と身体診察を極めよう、OSCEに向けて：めまい / Unleash your Mastery - The art of history taking and physical examination: Dizziness

OSCE

Hello everyone!!!

Let's continue mastering history taking and physical examination!

こんにちは～

今日も問診・診察を極めて行きましょう！

 

Today, I studied dizziness.

It seems like a complex symptom with many considerations

By focusing on the basics and studying it carefully

it feels like my aversion to it has decreased a bit..., though

今日は、めまいについて勉強しました

考えることが多そうで、複雑そうな症状ですが

基本を押さえて丁寧に勉強していくと、少しは苦手意識がなくなってきたような、、

 

I've summarized this often-avoided topic of dizziness

And I'm sharing it with all of you.

そんな敬遠されがちなめまいについてまとめたので

みなさんに共有しますね

 

If you come across any new insights or important points that I've missed,

Please feel free to share them with me

もし、新しい発見とか、これも大事だよ～ってことがあったら

せひせひ教えてください～～

 

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Understanding Dizziness: A Clinical Overview

Dizziness is a common yet complex symptom encountered in clinical practice, often posing a diagnostic challenge due to its broad differential diagnosis.

Definition and Types of Dizziness

Dizziness is a nonspecific term that describes a range of sensations, including lightheadedness, unsteadiness, and a false sense of motion. It can be broadly categorized into four main types:

  1. Vertigo: A false sense of spinning or motion, typically associated with inner ear disorders.
  2. Presyncope: A feeling of impending fainting or lightheadedness, often due to cardiovascular causes.
  3. Disequilibrium: A sense of unsteadiness or imbalance, frequently related to neurological or musculoskeletal issues.
  4. Non-specific Dizziness/Lightheadedness: A vague sensation that does not fit into the above categories, often associated with anxiety or hyperventilation.

Pathophysiology and Approach

Vertigo

  • Central: Characterized by vertical nystagmus. Causes include:
    • Cerebellar lesion (stroke, infection, multiple sclerosis)
  • Peripheral: Characterized by horizontal nystagmus. Causes include:
    • Benign Paroxysmal Positional Vertigo (BPPV)
    • Vestibular neuritis
    • Vestibular neoplasm
    • Meniere’s disease
    • Acute otitis media (AOM)

Presyncope

  • Cardiac Causes:
    • Arrhythmias
    • Valvular disease
    • Hypertrophic obstructive cardiomyopathy (HOCM)
    • Pulmonary thromboembolism (PTE)
  • Orthostatic Causes:
    • Hypovolemia
    • Autonomic dysfunction
    • Medications
  • Reflex Causes:
    • Vasovagal
    • Situational

Disequilibrium

  • Sensory Input Issues:
    • Neuropathy
    • Visual impairment
    • Medications/Toxins (e.g., ethanol, anticholinergics)
  • Autonomic Dysfunction:
    • Parkinson’s disease
    • Diabetes mellitus
    • Amyloidosis
  • Coordination/Strength Issues:
    • Vitamin B12 deficiency
    • Cerebellar disorders
    • Radiculopathy

Lightheadedness

  • Causes:
    • Anemia
    • Psychiatric disorders

Clinical Evaluation

A thorough clinical evaluation is essential for accurate diagnosis and effective management. Key steps include:

  • History Taking:
    • With or without inner ear symptoms (tinnitus, deafness)
    • Duration (seconds, minutes, days)
    • Context: triggers (e.g., position changes, head trauma)
    • Associated symptoms: nausea, visual disturbances, neurological signs
    • Past medical history: medications, atherosclerosis

                           Specific Questions and Useful Phrases:

    • General:
      • “Can you describe what you mean by dizziness?”
      • “When did you first notice the dizziness?”
      • “How long does each episode last?”
    • Vertigo:
      • “Do you feel like you or the room is spinning?”
      • “Do these episodes happen when you change positions, like turning over in bed?”
      • “Have you noticed any ringing in your ears or hearing loss?”
    • Presyncope:
      • “Did you feel like you were going to faint or pass out?”
      • “Do you experience this feeling when you stand up quickly?”
      • “Have you ever lost consciousness during these episodes?”
    • Disequilibrium:
      • “Do you feel unsteady on your feet or like you might fall?”
      • “Is it difficult to walk in a straight line?”
      • “Have you noticed any numbness or tingling in your feet or legs?”
    • Lightheadedness:
      • “Do you feel lightheaded, like you might faint?”
      • “Do you feel like your head is swimming or foggy?”
      • “Does this feeling come on suddenly or gradually?”

  • Examination:

  1. Physical Examination:
      • Vital Signs: Blood pressure, heart rate, respiratory rate, SpO2
      • Chest and Heart Examination: Look for signs of cardiovascular issues
      • Jugular Venous Distension (JVD): Assess for heart failure
      • Neurological Examination: Check for nystagmus, perform finger-to-nose and knee-heel tests
      • Other Examinations: ENT, digital rectal exam if indicated
  2. Diagnostic Tests:
      • Electrocardiogram (EKG): To rule out cardiac causes
      • Laboratory Tests: Hemoglobin, hematocrit, BUN/creatinine, electrolytes
      • Imaging: Chest X-ray (CXR) if indicated
      • Audiometry: For hearing loss associated with vestibular disorders
      • Imaging (MRI/CT): If central causes are suspected

Management Strategies

Management of dizziness depends on the underlying cause:

  • Vertigo:
    • BPPV: Canalith repositioning maneuvers (e.g., Epley maneuver)
    • Meniere’s Disease: Dietary modifications (low salt), diuretics, vestibular rehabilitation
    • Vestibular Neuritis: Corticosteroids and vestibular exercises
  • Presyncope:
    • Orthostatic Hypotension: Increase fluid and salt intake, compression stockings, and medications (e.g., fludrocortisone)
    • Cardiac Causes: Specific treatment for arrhythmias or structural heart disease
  • Disequilibrium:
    • Neurological Disorders: Physical therapy and treatment of the underlying condition
    • Musculoskeletal Issues: Strengthening exercises and addressing joint instability
  • Non-specific Dizziness:
    • Anxiety or Depression: Cognitive-behavioral therapy (CBT), relaxation techniques, and selective serotonin reuptake inhibitors (SSRIs)

🚩Red Flags and Critical Conditions

It's crucial to rule out serious conditions such as:

  • Cerebellar/brain stem infarction or hemorrhage
  • Wallenberg syndrome
  • Cardiovascular causes
  • Severe anemia or hypovolemia

Use the San Francisco Syncope Rule: 

to predict the risk for serious outcomes in patients presenting with syncope or presyncope. 

Criteria include: CHESS

  • Congestive heart failure
  • Hematocrit under 30% (severe anemia)
  • EKG abnormalities (e.g., bradycardia, sick sinus syndrome, paroxysmal supraventricular tachycardia/ventricular tachycardia)
  • Shortness of breath
  • Systolic blood pressure less than 90 mmHg

 

  1. Baloh RW. Dizziness. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 409.
  2. Strupp M, Magnusson M. Diagnostic approach to dizziness. Neurol Clin. 2005 May;23(2):387-405, vi. doi: 10.1016/j.ncl.2004.10.002.
  3. Tusa RJ, Furman JM. Dizziness. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley's Neurology in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016:chap 44.
  4. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Nov 22;183(9):E571-92. doi: 10.1503/cmaj.100174.
  5. Edlow JA. Diagnosing dizziness: we are teaching the wrong approach. Ann Neurol. 2013 Nov;74(5):742-50. doi: 10.1002/ana.24096