the patient is admitted following a report of dizziness

Is dizziness in the emergency department a problem presentation?

Keywords: Vertigo, dizziness, emergency department, stroke, vestibular neuritis, benign paroxysmal positional vertigo Introduction Dizziness can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint.

What are the evaluation of the patient with dizziness?

The evaluation of a patient with dizziness 1 Acute prolonged severe dizziness. Patients who present with new onset severe dizziness, imbalance,... 2 Recurrent spontaneous attacks of dizziness. 3 Recurrent positionally triggered dizziness. 4 Chronic persistent dizziness. Anxiety disorders commonly present with chronic continuous dizziness.

What is the psychophysiology of dizziness?

Some patients describe their dizziness as an out-of-body experience, floating, or an internal spinning sensation (i.e., no visualized spinning of the environment). These descriptions suggest a psychophysiological symptom (i.e., a combination of psychiatric factors and physiologic responses such as hyperventilation or neurotransmitter release).

What are the signs and symptoms of recurrent episodes of dizziness?

Patients may present during an attack or after the attack has already ended. Meniere’s disease is the prototypical disorder characterized by recurrent spontaneous episodes of dizziness. Patients with this disorder have severe episodes of dizziness – generally true vertigo – with nausea, vomiting, and imbalance.

What should you do if a patient is dizzy?

1. Treat SymptomsThe person should sit down or lie still.If the person gets light-headed when standing up, the person should stand up slowly.Avoid sudden changes in position.If the person is thirsty, have them drink fluids.Avoid bright lights.

What causes dizziness in a patient?

Dizziness has many possible causes, including inner ear disturbance, motion sickness and medication effects. Sometimes it's caused by an underlying health condition, such as poor circulation, infection or injury. The way dizziness makes you feel and your triggers provide clues for possible causes.

How do you get admitted to the hospital for dizziness?

If dizziness is accompanied by any of the following symptoms, you should also seek emergency care:Difficulty walking.Dizziness associated with trauma.Double vision and loss of vision.Headache.Numbness or weakness in the muscles.Slurred speech.Vomiting.

How do you describe dizziness?

Dizziness is disorientation in space, lightheadedness, or a sense of unsteadiness. It affects your sense of balance and can increase your risk of falling....When you're dizzy, you may feel:Faint.Lightheaded.Nauseous.Unsteady.Woozy.

What are the causes of dizziness and weakness?

What Causes Dizziness and Fatigue? 9 Possible CausesHypoglycemia.Hypotension.Anemia.Migraines.Medications.Abnormal heart rhythms.Chronic fatigue.Vestibular neuronitis.More items...

When should you worry about dizziness?

Generally, see your doctor if you experience any recurrent, sudden, severe, or prolonged and unexplained dizziness or vertigo. Get emergency medical care if you experience new, severe dizziness or vertigo along with any of the following: Sudden, severe headache. Chest pain.

What is the reason for dizziness and vomiting?

inner ear problems, which can cause a loss of balance, resulting in dizziness and vomiting. heart conditions, such as a heart attack or stroke. internal bleeding, which can result from trauma to the body and lead to dizziness and vomiting due to blood loss. ingesting poison or breathing in harmful chemicals.

What causes dizziness and sweating?

You can faint if your brain isn't receiving enough oxygen. This most often happens due to a sudden drop in blood pressure. Prior to fainting, a person may experience feelings of dizziness or lightheadedness. In some cases, sweating may also occur.

What does dizziness and nausea mean?

If you get nausea along with it, it could be due to problems like vertigo, migraine, or low blood pressure. Usually, dizziness with nausea isn't serious. But if you have these symptoms and you don't know what caused them, or they happen often, tell your doctor.

How do you describe dizziness to the doctor?

Lightheadedness, as though you might pass out. Unsteadiness or a loss of balance. A false sense that you or your surroundings are spinning or moving (vertigo) Floating, swimming or heavy-headedness.

What is medical name for dizziness?

Vertigo is a sensation of motion or spinning that is often described as dizziness.

What is a synonym for dizziness?

In this page you can discover 20 synonyms, antonyms, idiomatic expressions, and related words for dizziness, like: vertigo, vertiginousness, blurred-vision, sleeplessness, tiredness, awareness, nausea, lightheadedness, wooziness, drowsiness and palpitation.

What is the temperature of an older adult patient?

Vital signs documented on an older adult patient in the outpatient clinic are recorded as: Temperature: 98.6F (37.0C), Pulse: 68, Respirations: 30, B/P 128/84 mmHg. Which of the following measurements should the medical assistant reassess?

What does a medical assistant measure?

The medical assistant measures the patient's blood pressure at 178/108 (mmHg) during the check-in process. Which of the following actions should the medical assistant take?

How many breaths per minute does an adult have?

The adult patient's respiratory rate is 18 breaths per minute, with no apparent distress. This finding

Can a drug cause addiction?

B. Narcotics will cause addiction if administered to manage pain.

What happens after spinal cord injury?

After a few days of receiving the medication, the patient experiences sedation, fatigue, dizziness, and changes in mental status. Which medication does the nurse anticipate has contributed to these symptoms?

What is tizanidine prescribed for?

A patient with severe muscle spasticity has been prescribed tizanidine. The nurse instructs the patient about which adverse effect of tizanidine?

Does the chest move with each respiration?

The patient's chest moves very little with each respiration.

How to treat acute dizziness?

The management of the acute dizziness presentation begins with supportive care. If stroke is suspected then a neuro-imaging study should be considered. Though CT could serve as the initial study, a normal result on CT should provide little confidence that stroke can be excluded. In this situation, an MRI or hospital admission for close observation should be considered. If stroke is confirmed to be the cause and the patient presents within three hours of onset, thrombolytic treatment should be considered. A short course of corticosteroids should be considered for patients with vestibular neuritis. A randomized controlled trial showed that patients with vestibular neuritis treated with corticosteroids within three days of symptom onset had a higher likelihood of recovery of the peripheral vestibular caloric response at 12 months.19However this study did not test whether the patient’s functional or symptomatic outcome improved, and corticosteroids are not without potential side effects. After the initial severe symptomatic time period, it is important that patients resume activities because this helps the brain to compensate for the asymmetry of vestibular signals. A formal vestibular therapy program has been shown in a randomized trial to improve outcomes in patients with vestibular neuritis.20

What is a head thrust test?

A recently described bedside test, the “head-thrust test,” is now an important component of the bedside evaluation in acute severe dizziness presentations. 11, 12The test allows the examiner to assess the vestibulo-ocular reflex (VOR) on each side. The VOR is the component of the vestibular system that triggers eye movements in response to stimulation. In different settings, the VOR has long been tested using the doll’s eye test of the coma exam and caloric stimulation (i.e., the laboratory caloric test or the bedside cold caloric test in a comatose patient). To test the VOR using the head thrust test, the examiner stands in front of the patient and grasps the patient’s head with both hands. The patient is instructed to focus on the examiner’s nose and then the examiner initiates a quick 5-10° movement of the pa tient’s head to one side. When there is a lesion of the VOR on one side – as occurs with vestibular neuritis – a corrective eye movement (i.e., a corrective “saccade”) back to the examiner’s nose is seen after the head is moved toward the affected side.12In contrast and serving as an internal control, the eyes will stay on target (i.e., the examiner’s nose) after the head thrust test toward the normal side because the VOR is intact on that side. These features can be appreciated even when spontaneous nystagmus is present. The reason for the corrective saccade with a peripheral vestibular lesion is rooted in the physiology of the vestibular system.10When the head is moved quickly in one direction, the reflex (i.e., the VOR) that moves the eyes toward the opposite direction is generated by the side the head moved toward. Thus a patient with vestibular neuritis of the left side will present with right-beating unidirectional nystagmus and have a positive head thrust test with movements toward the left side.

How to identify nystagmus in vestibular neuritis?

Following this initial time period, the nystagmus may only be identified during gaze testing (i.e., having the patient look to each side) or if visual fixation is blocked. Patients can suppress peripheral vestibular nystagmus by visual fixation on a target, so removing the patient’s ability to fixate can bring out the spontaneous nystagmus. The simplest way to block fixation is to place a blank sheet of paper a few inches in front of the patient and then observe for spontaneous nystagmus from the side.

What is the alternating slow and fast movement of the eyes?

Nystagmus is a term used to describe alternating slow and fast movements of the eyes. These alternating movements give the appearance that the eyes are beating toward one or more directions. Patients with vestibular neuritis have a peripheral vestibular pattern of nystagmus. In this setting, the peripheral vestibular pattern is a unidirectional, principally horizontal pattern of nystagmus. This description means that the nystagmus beats is in only one direction (i.e., a left-beating nystagmus never converts to right-beating, or a right-beating nystagmus never converts to left-beating). Conversely, bi-directional gaze-evoked nystagmus (i.e., right beating nystagmus present with gaze toward the right, and left-beating nystagmus present with gaze toward the left side) is a central nervous system pattern of nystag mus.10Other central nervous system patterns are pure torsional nystagmus or spontaneous vertical (typically downbeat) nystagmus. With an acute peripheral vestibular lesion, the only pattern of nystagmus that can result is unidirectional nystagmus. In acute severe dizziness presentations, any other pattern should be considered a central nervous system sign. Patients often prefer to keep their eyes closed early on, but the eyes should be opened and the pattern of nystagmus defined.

What is the name of the disorder that causes dizziness?

Episodes are variable in duration but generally will last for hours. The type of tinnitus experienced by patients with Meniere’s disease is typically very different from the more common constant bilateral high pitched tinnitus or the fleeting mild tinnitus that most people experience at some time. The tinnitus in Meniere’s disease is usually a very loud roaring sound in one ear. Though the nystagmus may not follow all the rules of peripheral vestibular nystagmus described in vestibular neuritis, the same red flags for central causes (i.e., down-beat, pure-torsional, or bi-directional gaze-evoked nystagmus) apply. The head thrust test is generally normal in patients with Meniere’s disease since the peripheral vestibular system is intact.

What is central positional vertigo?

Central positional vertigo stems from a lesion of the cerebellum or the brainstem. Positional vertigo and nystagmus are common features of a Chiari malformation, cerebellar tumor, multiple sclerosis, migraine vertigo, and degenerative ataxia disorders. As with the acute dizziness presentations, the key to distinguishing a central nervous system disorder from a peripheral vestibular disorder is the pattern of nystagmus. The most common pattern of central positional nystagmus is pure down-beating nystagmus that lasts as long as the position is held. Pure torsional nystagmus is another type of central positional nystagmus. The pattern of nystagmus seen with horizontal canal BPPV can also be caused by a central lesion. A general rule is that a central nervous system cause of positional nystagmus should be considered whenever the pattern of nystagmus is a persistent downbeating nystagmus, pure-torsional nystagmus, or whenever the nystagmus is refractory to repositioning maneuvers.

What is BPPV in a patient?

Benign paroxysmal positional vertigo ( BPPV) is the likely cause in patients reporting brief recurrent attacks of dizziness triggered by changes in head position. It is important to recognize this cause because it can be readily treated at the bedside and because identification of the key features is the most effective way to exclude a central nervous system cause of positional dizziness. Important points about BPPV are that the dizziness episodes last less than one minute and patients are normal in between episodes. Sometimes nausea or a mild lightheadedness can persist longer than one minute, but any patient reporting positional dizziness lasting longer than one minute should be carefully scrutinized for other potential causes. A patient with dizziness from any cause will feel worse with certain position changes, but the patient with BPPV has dizziness that is triggered by positional changes and then returns to normal between attacks. Patients with vestibular neuritis are often misclassified as BPPV because the symptoms improve when the patient remains still and worsen with movement, but that is very different than the patient who returns to normal at rest.

What is the first step in assessing a patient presenting with dizziness?

The first step in assessing a patient presenting with dizziness is to define the symptom (table 1). The patient's report is subjective and thus can be unreliable and inconsistent.2For example, vertigo, defined as an illusion of movement, indicates an imbalance within the vestibular system. However, just because a patient reports “vertigo” does not mean that the cause is a vestibular disorder; similarly, just because a patient denies vertigo does not mean that a vestibular disorder is excluded. Even patients with obvious vestibular nystagmus during caloric testing may deny vertigo, and instead report a feeling of lightheadedness, “wooziness,” or disorientation. Lightheadedness is a very nonspecific type of dizziness. When accompanied by a near-faint symptom, it is suggestive of diffuse decreased cerebral blood flow, such as occurs with cardiac arrhythmia or orthostatic hypotension. But lightheadedness also occurs with anxiety, metabolic derangements, drug intoxication, and vestibular disorders. Some patients describe their dizziness as an out-of-body experience, floating, or an internal spinning sensation (i.e., no visualized spinning of the environment). These descriptions suggest a psychophysiological symptom (i.e., a combination of psychiatric factors and physiologic responses such as hyperventilation or neurotransmitter release). Some patients, particularly patients with migraine, are chronically sensitive to motion (self and surround). Genetic factors presumably are important but the mechanism is unknown. Disequilibrium refers to a sense of unsteadiness when standing or walking and is a common accompanying symptom of vertigo or lightheadedness.

What is the most common oculomotor abnormality observed in patients with dizziness?

In primary gaze, the most common oculomotor abnormality observed in patients with dizziness is spontaneous nystagmus. Finding spontaneous nystagmus indicates an imbalance within the central or peripheral vestibular system. A unidirectional horizontal spontaneous nystagmus (e.g., a spontaneous left-beating nystagmus that does not convert to right-beating on gaze testing to the right) is characteristic of an acute peripheral vestibular imbalance, but this pattern can also occur in lesions of the central vestibular pathways. Spontaneous vertical or pure torsional nystagmus indicates a central lesion.

How to perform Dix Hallpike?

The Dix-Hallpike test is performed by turning the patient's head about 45 degrees toward the side to be tested (step 1) and then laying the patient down quickly (step 2). If BPPV is present, nystagmus ensues usually within seconds. The patient is held in the right head-hanging position (step 2) for 20 to 30 seconds, and then the remaining steps of the canalith repositioning maneuver can be performed (steps 3–5). In step 3, the head is turned 90 degrees toward the unaffected side. Step 3 is held for 20 to 30 seconds before turning the head another 90 degrees (step 4) so the head is nearly in the face-down position. Step 4 is held for 20 to 30 seconds, and then the patient is brought quickly back up to the sitting up position. The movement of the otolith material within the labyrinth is depicted with each step, showing how otoliths are moved from the posterior semicircular canal to the vestibule. From: Fife T, Iverson T, Lempert J, et al. Practice parameter: therapies for benign paroxysmal positional vertigo. Neurology 2008;70:2067–2074.

What is the purpose of a dix-hallpike test?

The Dix-Hallpike test is used to diagnose the posterior semicircular canal variant of benign paroxysmal positional vertigo (BPPV) (figure 2, steps 1 and 2). With the patient sitting, the head is turned 45 degrees to the side placing the posterior canal on that side in the sagittal plain. The patient is then moved to the head-hanging position. If the patient has debris moving in the posterior canal, this will lead to a very specific pattern of nystagmus: a burst of upbeat-torsional nystagmus lasting about 15 seconds. Pure vertical nystagmus, particularly persistent downbeat nystagmus, suggests a central lesion, usually involving the midline cerebellum. If the Dix-Hallpike test is applied to a patient with vestibular neuritis, then the spontaneous unidirectional horizontal pattern of nystagmus will be accentuated. This “positional nystagmus” leads some clinicians to erroneously diagnose BPPV in patients with vestibular neuritis. To diagnose the horizontal canal variant of BPPV, the patient lies supine and the head is turned to one side and then the other inducing a transient horizontal nystagmus that changes direction based on the side of the head turn. In the most common form of horizontal canal BPPV, a head turn to the right leads to right-beating nystagmus, whereas a head turn to the left leads to left-beating nystagmus (the abnormal side is the side with the more intense nystagmus). In the less common form of horizontal canal BPPV, the nystagmus beats in the direction opposite the head turn.

How to perform a head thrust test?

To perform the head thrust test, the physician stands directly in front of the patient seated on the examination table. The patient 's head is held in the examiner's hands and the patient is instructed to focus on the examiner's nose. The head is then quickly moved about 10–15 degrees to one side. In patients with normal vestibular function, the VOR results in movement of the eyes in the direction opposite the head movement. This occurs very quickly such that the patient's eyes remain on the examiner's nose at all times during and after the sudden movement. The test is repeated in the opposite direction. Impairment of the VOR is identified when the eyes move off the target and a voluntary saccade (so-called refixation saccade) is observed bringing the patient's eyes back to the target after the head thrust test.

What is the focus of a neurologic exam?

The neurologic examination focuses on oculomotor function and balance.

Why is it important to define the characteristics of a symptom?

Because symptoms are subjective, defining the characteristics (e.g., onset, triggers, duration) of the symptom may be more important than defining the actual symptom. Patients tend to be more reliable and consistent with this information, which is critical to formulating the differential diagnosis.