Thursday, 5 January 2017

Decipher Dizziness aka “Giddiness”

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.


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.

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 !

(Image Courtesy: Bing Images

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