So let's talk through our approach to dizziness.
One of the challenges is patients describe dizziness
very differently.
Some people will say they're off balance,
others have weak spells,
lightheadedness is a common description.
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.
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.
So in the rest of this talk, will break down this approach.
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.
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.
Vertigo is described by patients as being rooms spinning
or spinning around the room.
That spinning quality is very common
for patients who are suffering from vertigo.
Vertigo arises from problems in the vestibular system,
so our diagnostic investigation will be focused on the vestibular system.
We'll learn that the vestibular system
is composed of a peripheral component
and a central component.
And so we're looking to differentiate
whether vertigo is coming from the peripheral nervous system
or the central nervous system.
The second broad category of dizziness is pre-syncope or syncope.
Patients will describe this as a woozy feeling
or being swimmy headed, or fainting.
And that lightheadedness description
should have us focus in on evaluation
of pre-syncope or syncope.
Pre-syncope and syncope come from the cardiovascular system.
And so again, our diagnostic investigation
is at the heart
the carotid vessels, or other blood vessels,
or low blood pressure.
The third category is dysequilibrium.
Dysequilibrium is that drunkenness feeling.
Patients describe this as being imbalanced or off balance
as being unsteady on their feet.
Dysequilibrium comes from a problem with the cerebellum
or cerebellar circuitry.
And so imaging the cerebellum and interrogating that circuitry
is often our initial step in the diagnostic approach
to dysequilibrium.
And then the last category is nonspecific dizziness.
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.
This has many descriptions.
Patients may say they feel giddy or giddiness, or jittery
and nonspecific dizziness, poorly localizes.
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.
These categories are very helpful when evaluating patients
and working through clinical vignettes.
So when I'm approaching patients or clinical vignettes
who are presenting with dizziness, I like to think about this table.
I start with the patient's report.
How does the patient describe their dizziness?
Is it spinning, lightheadedness, dizziness, or giddiness.
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.
From that I arrive at my own clinical description.
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.
If I'm worried about vertigo,
I'll interrogate the vestibular system
and really look at vestibular function on examination.
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.
And ultimately, this helps us with the workup.
Vertigo arises from the vestibular system
and we'll focus our diagnostic investigation there.
Or for pre-syncope, syncope on the heart,
and then MRI of the brain for cerebellar dysequilibrium.
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.