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Be alert to neurologic causes in patients who seek medical attention for dizziness

BOSTON — Given that dizziness is in the top five complaints for which patients seek medical attention, an excellent history and appropriate testing are critical to determine the cause or causes of dizziness, among which could be neurological conditions, said an expert here at the ACP Internal Medicine Meeting.

“I love dizziness. Dizziness is wonderful. We are going to convert you this morning. When you leave here today you are going to say to yourself ‘I can’t wait until I get back to my office and see first dizzy [patient]’ and you all know that isn’t going to be long,” Martin A. Samuels, MD, DSc(Hon), MACP, FAAN, FANA, began light-heartedly.

“[The] most important feature of all of medicine is the history. At the end of the history there are only two possibilities, either you know the answer or you will never know the answer,” he said, noting you should take an open-ended history.

Samuels said there are four major answers to a patient who has the compliant of dizziness: vertigo (illusion or hallucination of motion); near syncope (sensation of an impending fainting episode); imbalance (gait disorder); and the metaphorical use of the term dizzy to define anxiety. Most patients describe more than one type of dizziness. The average is 1.5 types, he said.

He provided tips on the examination of a patient who complains of dizziness, such as the fact that the orthostatic blood pressure and heart rate should be taken by you, the examiner. Also, he hyperventilates a patient in the squatting position then has them stand. He recommends not pressing on the carotid sinus. And finally, he recommends to always test gait, conduct the Romberg test, and the Fukuda Stepping test.

“Examine the patient carefully and come up with a theory before you order any tests,” Samuels said.

“The system is elegant,” Samuels said. “It is a system that tells our central nervous system two bits of information – angular acceleration of the head in the three planes (roll, pitch and yaw) and linear acceleration due to gravity.”

“Normal people are not dizzy because the system is relatively balanced and when it becomes imbalanced … you develop vertigo, which is the sensation of motion where there is no motion.”

Samuels noted during a case review that bi-directional nystagmus in a single position of the head always means a disorder of the central nervous system.

In another case, Samuels discussed the leg-crossing/thigh-clenching maneuver as an important clinical pearl to teach your patients with benign vasodepressor syncope.

These benign types of fainting can be helped considerably by this maneuver that squeezes the blood out of the lower extremities, he said.

“I tell people to cross their legs and bend over like you are going to tie your shoes and the sensation will pass,” he said.

He also recommends to be alert for patients who are taking meclizine and benzodiazepine. – by Joan-Marie Stiglich, ELS

For More Information:

Clinical Triad: Dizziness-Important Considerations in the Workup. Presented at: ACP Internal Medicine Meeting; April 30-May 2, 2015; Boston.

Disclosure: Samuels reports no financial disclosures.