00:01
So let's talk through
our approach to dizziness.
00:04
One of the challenges is
patients describe dizziness
very differently.
00:08
Some people will say
they're off balance,
others have weak spells,
lightheadedness
is a common description.
00:15
Self-referenced, vertigo,
wooziness, blacking out episodes,
loss of balance, tilting, syncope,
presyncope, unsteadiness
world-referenced vertigo, spinning
about the world rocking, spinning,
muddled brain, giddiness,
disorientation,
fainting, instability,
imbalance, swaying,
many descriptions
we can hear for patients
who are suffering dizziness.
00:45
As clinicians, we need
some way of categorizing this,
of grouping patient descriptions
into the types of things
that will cause the dizziness
and where we need to go looking.
00:55
So in the rest of this talk,
will break down this approach.
00:58
How we approach patients
and clinical vignettes,
to come up with
what the diagnosis is,
how we're going to
manage the patient,
and ultimately,
what our treatment will be?
So when we approach patients
in clinical vignettes,
we can really break these
myriad descriptions down
into four categories.
01:17
And we're looking to figure out
whether the patient's description
in the patient is describing
vertigo, syncope or presyncope,
dysequilibrium,
or nonspecific dizziness.
01:28
Vertigo is described by patients
as being rooms spinning
or spinning around the room.
01:33
That spinning quality
is very common
for patients who are suffering
from vertigo.
01:38
Vertigo arises from problems
in the vestibular system,
so our diagnostic investigation will
be focused on the vestibular system.
01:46
We'll learn that
the vestibular system
is composed of a
peripheral component
and a central component.
01:50
And so we're looking
to differentiate
whether vertigo is coming from
the peripheral nervous system
or the central nervous system.
01:58
The second broad category of
dizziness is pre-syncope or syncope.
02:02
Patients will describe this
as a woozy feeling
or being swimmy headed,
or fainting.
02:08
And that lightheadedness
description
should have us focus in
on evaluation
of pre-syncope or syncope.
02:15
Pre-syncope and syncope come from
the cardiovascular system.
02:18
And so again,
our diagnostic investigation
is at the heart
the carotid vessels,
or other blood vessels,
or low blood pressure.
02:28
The third category
is dysequilibrium.
02:30
Dysequilibrium is that
drunkenness feeling.
02:33
Patients describe this as being
imbalanced or off balance
as being unsteady on their feet.
02:39
Dysequilibrium comes from a problem
with the cerebellum
or cerebellar circuitry.
02:44
And so imaging the cerebellum
and interrogating that circuitry
is often our initial step
in the diagnostic approach
to dysequilibrium.
02:53
And then the last category
is nonspecific dizziness.
02:57
So if it's not vertigo, and
it's not pre-syncope or syncope,
and not dysequilibrium,
then we're probably dealing with
nonspecific dizziness.
03:06
This has many descriptions.
03:08
Patients may say they feel
giddy or giddiness, or jittery
and nonspecific dizziness,
poorly localizes.
03:15
So we don't look at a specific area
where that may arise from
but look at many conditions
that may cause
this poorly localized,
nonspecific dizziness.
03:25
These categories are very helpful
when evaluating patients
and working through
clinical vignettes.
03:31
So when I'm approaching
patients or clinical vignettes
who are presenting with dizziness,
I like to think about this table.
03:38
I start with the patient's report.
03:40
How does the patient describe
their dizziness?
Is it spinning, lightheadedness,
dizziness, or giddiness.
03:47
Patients don't always fall
into those four categories,
but I'm really trying to interrogate
the category of dizziness
that the patient is describing.
03:56
From that I arrive at my own
clinical description.
03:59
Do I think this is vertigo?
Is this pre or syncope
dysequilibrium,
or nonspecific dizziness
that we're dealing with?
That helps me on exam to focus
on my location of interest.
04:11
If I'm worried about vertigo,
I'll interrogate
the vestibular system
and really look at vestibular
function on examination.
04:19
Or with pre-syncope,
look at the cardiovascular system
with dysequilibrium,
comprehensive cerebellar testing,
or if it's nonspecific dizziness,
look at some of the
other contributing factors.
04:30
And ultimately,
this helps us with the workup.
04:33
Vertigo arises from
the vestibular system
and we'll focus our
diagnostic investigation there.
04:38
Or for pre-syncope,
syncope on the heart,
and then MRI of the brain
for cerebellar dysequilibrium.
04:45
And so this approach moving
from the patient's description,
to my clinical assessment
can be very helpful
when approaching patients
or clinical vignettes
for this dizzying topic.