From
the Desk of Sagar Galwankar, MD
Today I want to discuss
about another common complaint in Adult patients Emergency Departments often quoted as “Dizziness”
aka “Giddiness” which is NON TRAUMATIC.
This is a very crucial
complaint which requires a detailed history and clinical examination.
Vital Signs are very
important and when I say Vital Signs I mean Temperature Pulse Blood Pressure
and Respiration. Pulse Ox is also important.
I regularly ask for a
Bedside Blood Sugar and Patient to be put on a Monitor and a IV Line be placed.
I will discuss some
cases which brig out important aspects about this Major Masquerader.
Case
One
55-Year-Old Healthy Male
comes with Dizziness. Vital Signs Are Stable. Dizziness was sudden onset and patient
felt diaphoretic. The patient is having Vertigo too and says everything is
spinning.
There is Diabetes
Hypertension History of CAD/MI or a CVA.
Pt looks distressed and
feels everything is Spinning.
Vitals ordered and IV
Oxygen Monitor placed.
EKG CBC LFT RFT
Troponin and CXR and CT Head is ordered.
Orthostatic BP is
ordered and Pt is Orthostatic.
EKG Shows ST Elevation
MI and Patient is sent to Cath lab.
Case
Two
25-Year-old female
comes with Dizziness.
Patient is on her menses and feels very weak.
She is
restless and is saying that she can’t even stand.
Bleeding started today. She
is orthostatic positive.
Vitals , Vitals ordered
and IV Oxygen Monitor placed.
EKG CBC LFT RFT
Troponin Bedside UA and HCG Ordered.
HCG came back positive
and Ultrasound was done.
Patient had an ectopic
and was sent to Sx.
Case
Three
Patient comes with
Fever Dizziness and inability to maintain balance. 55 Years old Male. Diabetes
Hypertension + No H.O MI/CAD
Detailed Neuro exam
reveals Ataxia. Dizziness started one hour ago.
Vitals ordered and IV
Oxygen Monitor placed.
EKG CBC LFT RFT
Troponin and CXR and CT Head is ordered which is negative.
Pt continues to feel dizzy.
MRI/MRA Brain is
ordered and an Evolving CVA is diagnosed.
Pt gets Thrombolysis.
Case
Four
66 Year Old Female
comes with Dizziness.
Says she has uneasiness
in the chest and has bouts of dizziness.
When she feels dizzy
she has Palpitations in the heart and she feels short of breath.
Pt is obese and has
Diabetes Hypertension and is a Chronic Smoker with COPD.
Vitals ordered and IV
Oxygen Monitor placed.
EKG CBC LFT RFT
Troponin and CXR and CT Head is ordered which is negative.
Everything is negative
and Pt again has Tachycardia upto 140 and feels dizzy in the ED.
A CTA Chest is ordered
and she has Saddle Emboli in the Lung.
Case
Five
15 Year old Downs
syndrome Child comes with Mom complaining that “Room is spinning”
Clinical Exam is done. Neuro Exam is Normal.
ENT Exam reveals Fluid
in Middle ear.
CT Head is done and
patient has early Mastoiditis.
Treated with abx post
admission.
Case
Six
55 Year Old Female
comes with Dizziness and vertigo. This has increased in last one week.
No history of weakness
or chest pain or TIA or Anginal Symptoms
No Risk Factors
Vitals Orthostatic negative
Two sets of EKG Enzymes
CT Head CBC LFT RFT Negative.
Clinical Exam normal
Epley Maneuver is done and patient feels better and is
discharged after 4 hour observation.
Case Seven
35 Year Old male comes with extreme dizziness. Everything including
clinical exam and Labs and CT Head is negative.
Cardiac Markers negative.
Detailed Deep History reveals that patient was at a rave party and a UDS
reveals Amphetamines and Cocaine +
MRI/MRA Brain Reveals a Thalamic CVA
Case Eight
50 Year old Male comes with new onset dizziness. IV Oxygen Monitor and
Labs EKG Ordered . No Risk Factors, But is Obese.
Inverted T waves seen in anterior leads.
Pt says that he has been having chest and abdominal discomfort.
Abdomen is tender all over.
Rectal Exam Positive for Fresh Blood.
Patient gets a Lactate Ordered which is high and so is the white count.
CTA Abdomen done which reveals SMA Ischemia.
Patient goes to Sx.
Summary
Dizziness is
a great masquerader. Looks simple but can be a presentation of a life threatening
Medical Conditions.
The Recipe to
decipher Dizziness Evolves around a detail history keeping age and gender in
mind.
Diabetes and
Hypertension are risk factors for any Neuro Vascular or Cardiac
Acute Syndrome.
DKA and HTN Emergency are major causes of Dizziness and a IC
Bleed needs to be ruled out.
Vital Signs Orthostatic
and taking a detail history to R/O TIA / ACS is key
CBC LFT RFT
Trop EKG CT Head and UA with Pregnancy Test (In Females in Pregnancy Age group
w/o Hysterectomy) are basic labs.
When you do a
clinical Exam do ask about H/O PE , Thyroid Issues, Pacemaker Status and H.O CA
or MI
Fever with dizziness could be early sign of
meningitis / encephalitis/ brain abscess so do an LP and a CT Head
GI Bleed,
Ectopic Pregnancy are also presentations which cannot be missed.
Arrhythmia
could indicate cardiac ischemia or a conduction defect which may also be
related to drug abuse or endocrinal disorders like thyroid storm.
A Drug abuse
history is important and Pulmonary Embolism has many unconventional
presentations.
Stress
Anxiety are also diagnosis which can be present when all major causes are ruled
out.
Abuse also
should be considered.
Examining the
ears and eyes and considering Ear Pathologies and Glaucoma can be a cause.
I will admit a
patient if I suspect a TIA or ACS even though everything is negative. Ataxia is
a Major factor which decides admission for me.
Admitting
other conditions like GI Bleed Ectopic SMA Syndrome is a no brainer.
Dizziness can
be an allied presentation of something very different, so remember that.
Ask for history of Trauma Syncope Fall Head Injury: The patient may not tell you that initially unless you ask.
Ask for history of Trauma Syncope Fall Head Injury: The patient may not tell you that initially unless you ask.
When you have many patients in the ED
with Different Presentations and one of them is Dizziness- Remember there is
more to just being DIZZY !
Happy New Year to all !
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