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Narrowing the Differential Diagnosis With Dizziness
Narrowing the Differential Diagnosis With Dizziness s a senior family nurse practitioner student and current emergency room nurse, I recently learned a great deal about working through a systematic differential list with the vague symptom of dizziness. Sue, age 44 years, was my assigned patient. With a sudden onset of dizziness during lunch with her husband, she had become instantly nauseated, unsteady on her feet, and flushed and began having palpitations and shortness of breath. She denied chest pain, any chest pressure, numbness, tingling, or weakness to either side of her body. She also denied hearing loss or a recent illness. With this presentation looking initially like an atypical cardiac presentation, I wanted to send her to the emergency room for an expensive cardiac workup. However, with the help of my preceptor, we worked through the differential list for dizziness (Figure 1) and quickly diffused the situation with a diagnosis of benign paroxysmal positional vertigo versus acute labyrinthitis. Her history was significant for vertigo and nystagmus to the right, which was worse with the right eye, no tinnitus, no hearing loss, no recent upper respiratory sinus infection, and no increased stress at home. Physical examination revealed a normal neurological examination, normal EENT examination, negative orthostatic blood pressures, and overall normal examination with the exception of nystagmus to the right and positional vertigo.
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AWESOME ASSIGNMENT Barbara A. Petersen
Diagnostics performed included an electrocardiogram (normal sinus rhythm), complete blood cell count, chemical profile, Thyroid stimulating hormone (TSH) with reflex T4, and lipid profile. The patient was also scheduled for an outpatient magnetic resonance imaging of the head. The tests were performed primarily because she had not been in the clinic for almost a year, and magnetic resonance imaging was scheduled mainly due to the anxiety level of the patient and her husband. He had recently experienced a myocardial infarction just a few months previously. Treatment was with meclizine (Antivert), with the dosage tapered as symptoms decreased. Sue was instructed to return to the clinic or emergency room immediately if symptoms worsened or new symptoms appeared and then follow up in 2 to 3 days for laboratory results and re-evaluation. Sue was a great assignment because I learned to look deeper at a differential list, work through that list systematically, and rule out diagnoses as I went. A thorough history and physical examination and a good differential list saved this family a great deal of money in unwarranted diagnostics and a great deal of stress, all for simple vertigo. Barbara A. Petersen, RN, BSN, is a senior family nurse practitioner student at Clarkson College in Omaha, Neb. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2005.12.016
Please address your submissions to [email protected]. We look forward to publishing your stories. www.npjournal.org
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Vertigo
R/O 1. Orthostasis 2. Cardiac arrhythmia 3. CVA 4. Multiple sclerosis 5. CNS drugs
Benign Positional Vertigo
Observe (1) or Refer for Semont/Epley Maneuver
Positional or + Dix-Halipike
ENT Exam (1)
Hearing loss
Recent viral illness Audio if hearing decreased
Refer or R/O 1. Meniere’s 2. Acoustic neuroma 3. Toxic labyrinthitis 4. Ototoxic drugs 5. Barotrauma 6. Neurosyphilis 7. Other
Observe (2) Persistence > 6 weeks
ENT Referral
Figure 1. Differential list for vertigo. CNS indicates central nervous system; CVA, cerebrovascular accident; ENT, ear, nose, and throat (specialist) and R/O, rule out. Reprinted with permission from Davidson TM. Ambulatory healthcare pathways for ear, nose and throat disorders. UCSD Otolaryngology Head and Neck Surgery; February 4, 2000. Available at: http://www-surgery.ucsd.edu/ent/DAVIDSON/Pathway/index.html. Accessed October 28, 2005.
130
February 2006
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AWESOME ASSIGNMENT Barbara A. Petersen
Diagnostics performed included an electrocardiogram (normal sinus rhythm), complete blood cell count, chemical profile, Thyroid stimulating hormone (TSH) with reflex T4, and lipid profile. The patient was also scheduled for an outpatient magnetic resonance imaging of the head. The tests were performed primarily because she had not been in the clinic for almost a year, and magnetic resonance imaging was scheduled mainly due to the anxiety level of the patient and her husband. He had recently experienced a myocardial infarction just a few months previously. Treatment was with meclizine (Antivert), with the dosage tapered as symptoms decreased. Sue was instructed to return to the clinic or emergency room immediately if symptoms worsened or new symptoms appeared and then follow up in 2 to 3 days for laboratory results and re-evaluation. Sue was a great assignment because I learned to look deeper at a differential list, work through that list systematically, and rule out diagnoses as I went. A thorough history and physical examination and a good differential list saved this family a great deal of money in unwarranted diagnostics and a great deal of stress, all for simple vertigo. Barbara A. Petersen, RN, BSN, is a senior family nurse practitioner student at Clarkson College in Omaha, Neb. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2005.12.016
Please address your submissions to [email protected]. We look forward to publishing your stories. www.npjournal.org
129
Vertigo
R/O 1. Orthostasis 2. Cardiac arrhythmia 3. CVA 4. Multiple sclerosis 5. CNS drugs
Benign Positional Vertigo
Observe (1) or Refer for Semont/Epley Maneuver
Positional or + Dix-Halipike
ENT Exam (1)
Hearing loss
Recent viral illness Audio if hearing decreased
Refer or R/O 1. Meniere’s 2. Acoustic neuroma 3. Toxic labyrinthitis 4. Ototoxic drugs 5. Barotrauma 6. Neurosyphilis 7. Other
Observe (2) Persistence > 6 weeks
ENT Referral
Figure 1. Differential list for vertigo. CNS indicates central nervous system; CVA, cerebrovascular accident; ENT, ear, nose, and throat (specialist) and R/O, rule out. Reprinted with permission from Davidson TM. Ambulatory healthcare pathways for ear, nose and throat disorders. UCSD Otolaryngology Head and Neck Surgery; February 4, 2000. Available at: http://www-surgery.ucsd.edu/ent/DAVIDSON/Pathway/index.html. Accessed October 28, 2005.
130
February 2006