Jacobi Internal Medicine Chiefs Profile picture
Jul 31, 2019 18 tweets 12 min read Read on X
Last week we had our traditional lecture on Dizziness by our amazing PD, Dr @AndrewGutwein!...
As you are probably very aware, this is a very common complain!, and can have many subtleties.

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#JacobiIM #JacobiNoonConference #medtwitter #FOAMed #DDx @CPSolvers @DxRxEdu
Dizziness is VERY relative...
Patient can describe it as spinning, lightheaded, "blacking out", but sometimes, it is just "Dizziness".

Newman et al evaluated the overlap of dizziness categories based on symptoms. (May Clin Proceedings, 2007-11-01,Vol 82,1)

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#JacobiIM Image
But if it is just dizzy...DON'T STOP AT "JUST DIZZY"...try to really understand what is it!....As Dr Gutwein, says, "Dizziness is Meaningless".
A good way to try to understand what the patient means is:

3/n
#JacobiIM Image
Let's talk about a useful classification based on the etiology suggested by Dr Gutwein. Let's start with Vertigo:

4/n
#JacobiIM Image
Vertigo is described a sensation of 𝗺𝗼𝘁𝗶𝗼𝗻. It is usually described as a spinning sensation (either the room or the pt) but could be lateral like on a boat.

5/n
#JacobiIM
An important step is differentiating central vs peripheral vertigo. The HINTS exam is a series of bedside test that has = or > Sens as MRI for central etiology.

If none of the components of the HINTS suggest central etiology, likely it is peripheral.

6/n
#JacobiIM Image
Peripheral vertigo: time course and symptoms characteristics are very helpful. The most common etiologies are BPPV and vestibular neuritis, with many other less common etiologies including Meniere's and Alternobaric vertigo (from atm pressure changes)

7/n
#JacobiIM Image
If you suspect BPPV, the Dix Hallpike maneuvre is a good diagnostic test. Here is a nice video from @bmj_latest showing how to perform it. Remember, it is positive if you elicit nistagmus, so it doesn't make any sense doing it if the patient already has it!
8/n
#JacobIM
Let's move to the next category on our schema, 𝗣𝗿𝗲-𝘀𝘆𝗻𝗰𝗼𝗽𝗲.

#JacobiIM Image
(Pre-) Syncope is a very broad topic, and could be a tweetorial on its own, but all the categories share:
-Not enough Blood to CNS
-Low O2 to CNS
-Low Glucose to CNS

This explain in this amazing graph by @escardio - syncope guidelines doi.org/10.1093/eurhea…
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#JacobiIM Image
@CPSolvers have an amazing approach to syncope, dividing it in 3 big categories. Again, the description of the episode is crucial, as this can point towards a specific etiology.

Features such as excertional/supine episodes, no prodrome, etc can suggest high risk

#JacobiIM

10/n Image
A good HPI/PE (including orthostatic BP), maybe a CBC and an EKG and carefull medication reconciliation can lead to a diagnosis without further work up.
Remember, cardiac etiology is the one we are concerned, it has a higher mortality.
#JacobiIM

11/n
Next, 𝗗𝘆𝘀𝗲𝗾𝘂𝗶𝗹𝗹𝗶𝗯𝗿𝗶𝘂𝗺.

This is usually described as 𝙞𝙢𝙗𝙖𝙡𝙖𝙣𝙘𝙚 or 𝙪𝙣𝙨𝙩𝙚𝙖𝙙𝙞𝙣𝙚𝙨𝙨. Behind it there is usually an imbalance in our sensory input. This includes our vision, propioception and sensitive input.

#JacobiIM
12/n Image
This could be divided on 𝘼𝙪𝙩𝙤𝙣𝙤𝙢𝙞𝙘 𝘿𝙮𝙨𝙛𝙪𝙣𝙘𝙩𝙞𝙤𝙣, 𝘿𝙚𝙘𝙧𝙚𝙖𝙨𝙚𝙙 𝙨𝙚𝙣𝙨𝙞𝙩𝙞𝙫𝙚 𝙞𝙣𝙥𝙪𝙩 and 𝙄𝙢𝙥𝙖𝙞𝙧𝙚𝙙 𝘾𝙤𝙤𝙧𝙙𝙞𝙣𝙖𝙩𝙞𝙤𝙣/𝙎𝙩𝙧𝙚𝙣𝙜𝙝𝙩.

There is usually >1 cause, and many etiologies have >1 pathophysiology.

#JacobiIM
13/n Image
Again, a good history, physical exam and medication reconciliation are very important.

Although many are not amanable of being corrected (already stablish DM neuropathy), increasing the sensitive output through devices or PT can help.

#JacobiIM
14/n
Meds can leading to dizziness in several ways. Many can decrease propioception and sensinput (as EtOH, sedatives), but lead to neuropathy/vestibular dysfunction.
Vinca alkaloids, taxanes and Oxaliplatin are some chemotherapeutic agents that can cause neuropathy

15/n
#JacobiIM
Lastly, the "Others" category. This include less common etiologies such as CO poisoning, post-traumatic dizziness and psychogenic etiology. As this category is heterogeneous, careful exclusion of other causes should take place before any case is attributed.

16/n
#JacobiIM Image
Fin!. This is by no means a comprenhensive list of all causes, but rather a schema to approach to dizziness.

@CPSolvers

#JacobiIM #Tweetorial #FOAMed

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More from @jmcchiefs

Jun 28, 2019
Yesterday we had an amazing noon conference on scleroderma with Dr Bahce! We discussed from pathophysiology to the differential diagnosis and common complications...here are some tips and pearls!
1/n (systemic sclerosis) Image
Although there were many reports of patient with symptoms compatible with sclerodermia, the term was coined in the beggining of the 19th century by Fantonetti and Thirial.

However, the skin was though to be the only involved organ, with no relationship with other symptoms.
2/n
Osler described it as "scleroderma is one of the
most terrible of all human ills. The disease progress until one is literally a mummy, encased in an evershrinking, slowly contracting skin of steel, is a fate not pictured in any tragedy, ancient or modern"
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