Dizziness: Signs and Symptoms

by Roy Strowd, MD

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    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.

    About the Lecture

    The lecture Dizziness: Signs and Symptoms by Roy Strowd, MD is from the course Vertigo, Dizziness, and Disorders of Balance.

    Included Quiz Questions

    1. Care must be taken in obtaining the history, as patients use a wide variety of symptom descriptions.
    2. The patient’s report of the event is rarely helpful in diagnosis.
    3. Nonspecific dizziness is a benign condition that does not warrant further workup.
    4. Patients usually describe vertigo as a loss of balance or poor coordination.
    5. Presyncope should be suspected if the patient describes a spinning sensation.
    1. Carotid artery pathology usually presents as presyncope.
    2. Vertigo can only be caused by the central vestibular system.
    3. Presyncope workup usually starts with a brain MRI.
    4. Disequilibrium usually starts with a cardiovascular workup.
    5. Cerebellar pathology usually results in symptoms of presyncope.

    Author of lecture Dizziness: Signs and Symptoms

     Roy Strowd, MD

    Roy Strowd, MD

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