'I feel dizzy' doesn't have to mean a long workup
From the June ACP Observer, copyright © 2005 by the American College of Physicians.
By Deborah Gesensway
SAN FRANCISCO—From headaches to dizziness, many of the most common complaints patients bring to internists are neurological in nature. In fact, dizziness and headache are among the top five complaints—the others are back pain, chest pain and fatigue—for which adults seek help in primary care.
But many internists dread these visits, fearing the time and trouble they will take to work through, according to Martin A. Samuels, MACP, chair of the department of neurology at Boston's Brigham and Women's Hospital and professor of neurology at Harvard Medical School. Dr. Samuels held a full-day Annual Session pre-Session course on "Neurology for the Internist."
According to Michael J. Ruckenstein, MD, about 5% of multiple sclerosis patients present with vertigo.
That's especially true for patients who present with dizziness, said Michael J. Ruckenstein, MD, associate professor of otorhinolaryngology-head and neck surgery at Philadelphia's University of Pennsylvania, who held "A Practical Approach to Dizziness" session. But he assured internists attending the session that a diagnosis doesn't have to be that hard.
"For more than 90% of my dizzy patients," Dr. Ruckenstein said, "I know the diagnosis by the history."
For the rest, a neurological examination can usually add all that's needed, said Dr. Samuels. (For more tips, see "How to do a better neurological exam.") For a very few patients, imaging and other tests may still be necessary. But, Dr. Samuels cautioned, "it is unlikely that these tests will tell you more." Scans, such as CTs and MRIs, are likely to discern subclinical abnormalities that don't cause problems for the patient.
Although most patients with dizziness think it means they have a brain tumor, having one is actually very rare. But physicians need to know that patients have this common fear—and they should address it up-front.
"You must say at some point, 'By the way, this is not caused by a brain tumor,' " said Dr. Samuels, "They won't hear what else you have to say until you say that."
Martin A. Samuels, MACP, cautions internists that imaging and other tests are needed for only 'very few patients' with dizziness.
In addition, he said, internists should remember that many patients who come in complaining of dizziness, headache or other sensory problems are quite suggestible. This is the time to ask only open-ended questions and to talk directly to patients, not to family members who may accompany them. After all, Dr. Samuels reminded the group, only patients know what they've been feeling and how they want to describe it.
"Never suggest anything to a person with a sensory complaint," he said. "You will create a monster, and then they will become a chronic problem."
'Never suggest anything to a person with a sensory complaint. You will create a monster, and then they will become a chronic problem.'
—Martin A. Samuels, MACP
It's important to keep quiet and listen closely to what the patient is telling you. For instance, Dr. Samuels said, if patients say they have been dizzy lately, don't ask if the room seems to spin or if they feel like they are going to fall down. Instead, ask an open-ended question, such as, "What do you mean, 'dizzy?' " And then "stay mute" for as long as needed.
Also, he added, it's important to understand that patients mean the same sensation—dizzy—although they may use different terms. These include "vertigo," "woozie," "having a funny turn" or even clinical-sounding terms patients may have picked up searching the Internet.
Both Drs. Ruckenstein and Samuels pointed out that all dizziness falls into one of the following four categories:
True dizziness or psychogenic dizziness. It is these patients, usually young- to middle-aged women, who many physicians view with trepidation when they show up on the schedule. But Drs. Ruckenstein and Samuels said they are not hard to diagnose.
Typically, these patients report vague symptoms, like lightheadedness, that seem to get worse in busy places such as shopping malls and supermarkets. When you ask them to describe what they mean by dizzy, Dr. Samuels said, they are the ones who answer, "You know—dizzy."
"The key to these patients is that you are frustrated after you talk to them," Dr. Ruckenstein said. "They can lead a very experienced [medical] history taker down the wrong path …. The patient is almost a lot of things."
Their problem stems from anxiety, both physicians said. Patients can be successfully treated with cognitive behavioral therapy or SSRI-type antidepressants so long as the patient accepts the diagnosis.
Dr. Samuels suggested addressing their fears directly. Say: "This is not a brain tumor. This is not MS [multiple sclerosis]. This is true dizziness." Dr. Ruckenstein also stressed how important it is for primary care physicians to talk directly with patients about the diagnosis, using the conversation to "plant the seed in the patient's head" that anxiety is causing the dizziness. That way, patients who end up consulting subspecialists—and these patients tend to either doctor-shop or be referred by frustrated generalists—will be more likely to accept their findings and recommendations about therapy.
Vertigo. About half of all cases of dizziness are vertigo, which is defined as "an illusion or hallucination of motion," often rotational. (Patients often feel nauseous too.) Vertigo is when people say they feel the room is spinning.
According to Dr. Ruckenstein, patients with vertigo don't present with vague or "almost" symptoms. Instead, "people tell you clearly" what they are experiencing, he pointed out. "It's a scary feeling."
Internists need to figure out, based on history and physical findings, if the vertigo is caused by the central or peripheral nervous system. If it's central, doctors have to consider everything from strokes and MS to brainstem abnormalities and migraines. Between 10% and 15% of vertigo cases are migraine, Dr. Samuels said, while Dr. Ruckenstein said that about 5% of MS patients present with vertigo.
If it is peripheral, the key is to determine how long the spinning lasts and if there is accompanying unilateral hearing loss, Dr. Ruckenstein said. The most common type—benign positional vertigo—can last for only seconds or up to a minute, and usually occurs when a patient is lying in a position where a loose calcium crystal in the ear falls into one of the semicircular canals of the inner ear. These patients often report feeling vertigo after being in a dental chair, leaning back to get their hair washed at a hair salon or rolling over in bed.
For these patients, internists should learn to do the simple "Dix-Hallpike" test in their office to determine which ear is causing the problem. Then they should do the equally simple Epley maneuver. This clears up the problem for most patients almost instantly.
If the feeling of vertigo lasts longer or is accompanied by hearing problems, internists need to consider other possibilities, everything from retrocochlear tumors and viral or bacterial labyrinthitis to Meniere's disease. Dr. Ruckenstein, however, cautioned against jumping to a diagnosis of Meniere's disease, saying it has been "overused as a junk diagnosis."
Near syncope. The condition is also known as "presyncope." When you ask, "What do you mean, 'dizzy'?" these patients answer, 'I feel like I am going to faint,' " Dr. Samuels said. Patients typically feel dizzy when they stand up suddenly, as a result of a decrease in blood flow to the brain.
For these patients, internists need to figure out what is causing the temporary cerebral hypoperfusion. According to Dr. Ruckenstein, common culprits include antihypertensives, antianginal drugs, extreme heat, arrhythmias or vascular obstruction.
Ataxia or disequilibrium. People will describe this kind of gait-disorder dizziness by saying, "I feel like I'm going to fall." They sometimes use the word "balance" instead of "dizzy." Even non-professionals may notice something is odd: patients may mention that friends have said they're not walking straight, Dr. Ruckenstein said.
These patients are typically managed by neurologists, he said, and should be referred.
While taking a good history from a patient complaining of dizziness or headache may provide the most important information, conducting a neurological exam also can provide important clues, according to Martin A. Samuels, MACP, chair of the department of neurology at Boston's Brigham and Women's Hospital and professor of neurology at Harvard Medical School.
Despite all the recent and dramatic advancements in neurology, Dr. Samuels said, the neurological exam, which was invented in hospitals in Paris and London in the mid-1800s, "has stood the test of time for 150 years."
The six-part exam usually first evaluates the patient's mental status, both psychiatric and neurological. The rest of the exam looks at the cranial nerves, motor skills (having both too many and too few), senses, coordination and reflexes. Depending on the patient's complaint, the entire exam doesn't have to be done on all patients, but Dr. Samuels said he makes it a habit to always write up his evaluation in the same order and state outright what he omitted, so he doesn't accidentally forget one part.
An important component of the successful neurological exam, he said, is trust: Internists must trust their gut reactions to a patient's affect. For instance, if you sense that patients are sad, even though they are smiling and laughing, you have likely picked up on an important affect-mood dissociation. In addition, he said, it's important to record these feelings in your notes. They can be important clues.
"Always trust your feelings," Dr. Samuels said.
He offered the following tips to help internists get the most from neurological exams:
Learn to be comfortable saying "none" rather than "trace" when there really is no reaction to, say, a reflex test. Absent reflexes are always abnormal, usually reflecting a disorder of the peripheral nervous system such as neuropathy and radiculopathy, Dr. Samuels said.
Know when to stop. Think of a neurological exam as a Russian nesting doll—you can continue opening it to reveal more layers, but you can also choose to stop at any time.
For example, he said, if a patient's problem obviously has nothing to do with speaking or swallowing, don't examine the person's tongue. "This will make people nervous, especially anxious people," he said. "You have to know where to stop."
Another common example is looking at eye movements when there is no complaint about them. "Don't look for trouble," he said. "People complain about double vision if they have it. Don't look for it if they don't complain about it."
Always watch people walk. This can be a problem in an emergency room or in a hospital, but the surrogates for observing a person walk "are not good," he said.
In addition, avoid the temptation to think that age affects how a person walks. It is not normal for an older person to have a different gait than a young person, Dr. Samuels said. Gait changes, he added, are "due to the accumulation of disease."
Avoid using classic neurological tests that have little to offer. An example is the "serial 7s," in which patients count down by 7s—a hard task, said Dr. Samuels. "Lots of people can't do it when they are fine. There is no point in giving it."
He also advised against depending too much on the Mini Mental State Examination, which he said is too simple for physicians testing a patient's memory skills. It may be a useful test for laypeople to do, but physicians need to dig deeper. Instead, he recommended that physicians find out what the patient is or used to be interested in and then "have a detailed discussion on something they care about." Instead of relying on any standardized test, Dr. Samuels advised physicians to think through each patient individually.
"You have to think when you do [this exam] to get some richness out of it," he said.
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Internist Archives Quick Links
Internal Medicine Meeting Early Registration Discount
Register early for Internal Medicine Meeting 2015 in Boston, MA to lock in the lowest possible rate. Learn more or register now!
Are You Using ACP Smart Medicine®?
This online clinical decision support tool is a FREE benefit of ACP membership delivering point-of-care access to evidence-based recommendations. Includes more than 500 modules, images and reference tables. Start now or watch the video tour.