Family Medicine 33 A 28-year-old female with dizziness
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You are working with Dr. Barnett in his family medicine clinic. You meet with him in the morning in his office to go over the schedule for the day, and he tells you, “Our first patient, Mrs. Saleh, is fairly new to our practice. It looks like she called early this morning, and I’m glad we’re able to see her right away. We keep about half our daily appointments open until about 24 hours beforehand so that patients can come when they need to be seen and when it’s most convenient for them.”
“I saw Mrs. Saleh and her three children about a week ago. Her 4-month-old had a pretty bad acute otitis media that we needed to treat with antibiotics, so I’m not too surprised to see her in the clinic now. I think you will enjoy talking with her. Why don’t you obtain a history and perform a physical exam and then come tell me about your findings?”
Acute Otitis Media—Definition and Incidence Infection of the middle ear with incidence highest in children under six years old but peaks in children between 6 and 18 months of age.
Which of the following patients with otherwise uncomplicated respiratory tract infections require treatment with antibiotics?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. 2-month-old with acute otitis media
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B. 3-year-old with a fever of 38 °C (100.4 °F) and a two-day history of otitis media
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C. 18-year-old with no chronic medical conditions and a five-day history of acute maxillary sinusitis
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D. 28-year-old with adenovirus
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E. 32-year-old with community-acquired pneumonia
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F. 40-year-old with streptococcal pharyngitis
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G. 58-year-old with bronchitis
Choosing Wisely.org. Clinician Lists. American Academy of Family Physicians. Don’t routinely prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable. Updated July 2018. Accessed January 31, 2022.
Choosing Wisely.org. Clinician Lists. American Academy of Family Physicians. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for ten or more days, or symptoms worsen after initial clinical improvement. Updated July 2018. Accessed January 31, 2022.
Kaur R, Morris M, Pichichero ME. Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics. 2017;140(3):e20170101. Pediatrics. 2018;141(3):e20174067.
Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2013;2013(6):CD000247. Published 2013 Jun 4.
Lemiengre MB, van Driel ML, Merenstein D, Liira H, Mäkelä M, De Sutter AI. Antibiotics for acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2018;9(9):CD006089. Published 2018 Sep 10.
Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999.
Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2017;6(6):CD000245. Published 2017 Jun 19.
Todberg T, Koch A, Andersson M, Olsen SF, Lous J, Homøe P. Incidence of otitis media in a contemporary Danish National Birth Cohort. PLoS One. 2014;9(12):e111732. Published 2014 Dec 29.
You note that the nurse has recorded in the chart, “28-year-old patient with congestion, cough, and sore throat for four days.”
You go to see Mrs. Saleh. After introducing yourself, you ask a few questions:
You elicit the remainder of the history and perform a physical exam.
History
History of Present Illness: 28-year-old ill for four days. The patient reports that she felt feverish on day one, though that resolved by the second day. Nasal congestion, non-productive cough, sore throat. Does not have chills, rigors, myalgias, or arthralgias, changes in her sense of smell or taste, nausea, vomiting, or diarrhea. Her three children have been ill recently with similar symptoms and are improving with over-the-counter treatment. No allergies.
Medications: Acetaminophen and a night-time over-the-counter “cold and cough” medicine.
Herbal treatments: Mint tea.
Past medical history: Three spontaneous vaginal deliveries and her children are now four months, two years, and four years old. Immunizations are up-to-date, although she did not get a seasonal flu vaccine this year.
Social history: She has never smoked, and no one in the house smokes. She lives with her husband and their three children. She works as a seamstress, but she has had to miss a lot of work recently to stay home and take care of the children while they were sick.
Physical Exam
Vital signs:
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Temperature is 36.7 °C (98.2 °F)
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Pulse is 76 beats/minute
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Respiratory rate is 16 breaths/minute
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Blood pressure is 118/98 mmHg
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General appearance: Appears tired. Started crying during the history because “I feel so bad.”
Skin: Warm and dry.
Head, eyes, ears, nose, and throat (HEENT): Normal tympanic membranes. Nasal mucosa is erythematous. There is a clear nasal discharge. No sinus tenderness. Pharynx is mildly injected with no exudates.
Neck: No cervical lymphadenopathy.
Lungs: Clear to percussion and auscultation.
Cardiac exam: Regular rate and rhythm. Normal S1. S2. No murmurs, clicks, or rubs
Afterward, you let Mrs. Saleh know that you are going to talk to Dr. Barnett, and you’ll return with him in a moment.
As you leave the room, you try to recall the clinical features of the flu.
Which of the following are characteristic symptoms of seasonal flu?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Bloody diarrhea
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B. Fever
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C. Myalgia
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D. Scarlatiniform rash
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E. Shortness of breath
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F. Sore throat
The correct answers are B, C, F.
For a detailed description of the presentation of influenza, see Teaching Point below.
In adults, seasonal influenza classically presents with the abrupt onset of fever, myalgia, malaise, sore throat, and cough. These symptoms are very similar to the presentation of viral rhinosinusitis (the common cold), though the symptoms of influenza are typically more intense (eg. higher fevers) and may start more suddenly than those of a cold. Patients can sometimes recall the exact time and place that their symptoms started. In anyone presenting with such symptoms during a period of influenza activity, influenza should be high on the differential.
Gastrointestinal symptoms are not common with influenza in adults but can occur in up to 20% of cases in children. Rashes are not typically a part of influenza, though they can occur with the common cold.
The incubation period for seasonal influenza is typically between one and four days. The symptoms typically peak quickly and wane over four through seven days, though residual symptoms (eg. nasal congestion, cough, fatigue) may last for weeks in some cases.
It is worth noting that during the COVID-19 pandemic of 2020 and 2021, the management of patients with upper respiratory symptoms would be quite different from how it is depicted in the Aquifer cases to date. SARS-CoV2 infection, leading to the syndrome known as COVID-19, would be high on the differential of a patient presenting with cough, nasal congestion, and sore throat, given how widespread this virus has been throughout the pandemic. Due to the acute need to keep infected patients out of waiting rooms and other public spaces, patients with symptoms would not typically be seen in person first. They would first be evaluated by a telehealth encounter, whereupon they would be referred:
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For testing and isolation, if symptoms appear mild.
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For evaluation in a respiratory clinic (where appropriate infection control precautions are in place), if symptoms appear mild but other diagnoses need to be considered for which a physical exam and/or lab work are needed. Examples would include a patient with asthma or CHF who may be in exacerbation or a patient who may have strep throat.
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For evaluation in an ED, if symptoms are suggestive of severe COVID-19 disease.
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In the initial evaluation, it is important to assess a patient’s possible exposures, the timing of symptom onset, and any comorbidities or risk factors the patient may have.
SARS-CoV2 infection can lead to both asymptomatic infection and symptomatic COVID-19 disease. The proportion of infections that occur without symptoms is difficult to assess, but estimates range from 33% to 58%. For those patients who experience symptoms, the symptoms vary considerably from person to person and depend on the phase of the illness. Physicians should have a low threshold for ordering a test for COVID-19 in symptomatic patients.
Symptoms of early infection (viral phase)
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Cough
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Fever
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Anorexia
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Fatigue
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Anosmia
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Myalgias
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Chills
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Sore throat
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Nasal congestion
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Nausea and vomiting
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Diarrhea
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Dysgeusia (alteration in taste)
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Symptoms of early inflammatory phase (starts about 7 days after initial symptoms)
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Dyspnea
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Shortness of breath
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Altered mental status
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Respiratory failure
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Centers for Disease Control and Prevention. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm. Accessed September 23, 2020.
Cheng A, Caruso D, McDougall C. Outpatient Management of COVID-19: Rapid Evidence Review. Am Fam Physician. 2020;102(8):478-86.
You present your history and physical findings to Dr. Barnett. “I think she has a viral upper respiratory infection (URI) like her children. She doesn’t have a fever or myalgias that might make me think of influenza. Her ears are normal, so I don’t think she has otitis media. She has no purulent nasal discharge, and no sinus tenderness, so acute sinusitis does not seem likely. Her throat is a little red but has no exudates—and since she also has nasal congestion, no fever, and no lymphadenopathy, I would not be concerned about strep pharyngitis. Her cough is dry, and with no fever and a normal lung exam, it doesn’t seem like pneumonia. Plus, her whole family recently had the same thing. She doesn’t seem to have any indications of a bacterial infection, and I don’t think she needs antibiotics. But she is asking for some type of medication.”
“Yes,” Dr. Barnett responds, “based on what you’ve told me, I agree with your reasoning. Let’s go talk to her about treatment options. I usually find that my patients are happy not to take antibiotics once we respond and help them understand why. We can talk with her as well as share a handout on antibiotics: when they can and can’t help.
Which of the following options do you think best demonstrates an empathic response to a patient with a viral upper respiratory tract infection asking for antibiotics?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
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A. “Don’t worry. It’s only a cold. Everybody gets colds.”
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B. “I feel so sorry for you. I could never do it—take care of your family the way you do.”
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C. “It sounds like this sickness has really affected your life.”
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D. “I wish I could give you antibiotics, but national guidelines tell me not to.”
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E. “Maybe your husband could help out more at home so you can get some rest.”
The correct answer is C.
Although many of the above answers have components of an empathic response, the best answer is probably (C) because it demonstrates the clinician’s understanding of the patient’s experience of this illness without expressing judgment.
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Answer (A) may help to normalize the experience of the patient’s illness, but it also diminishes the patient’s own experience.
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Answer (B) demonstrates sympathy for the patient’s situation, but it returns the focus to the clinician’s emotional context rather than the patient’s.
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Response (D) negates the physician’s own best clinical judgment.
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Response (E) is a possible strategy for the patient to get more rest at home, but it does not reflect an understanding of the patient’s experience of her symptoms and may not be practical in the patient’s life situation.
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Empathy is the ability to understand the patient’s experience of illness, to acknowledge that experience, and to reflect that understanding back to the patient. Empathic responses enhance the doctor-patient relationship and positively affect medical outcomes.
Familydoctor.org. American Academy of Family Physicians. 2022. Diseases and Conditions. Colds and the Flu. https://familydoctor.org/condition/colds-and-the-flu/. Updated January 15, 2019. Accessed June 3, 2022.
Rakel DP, Hoeft TJ, Barrett BP, Chewning BA, Craig BM, Niu M. Practitioner empathy and the duration of the common cold. Fam Med. 2009;41(7):494-501.
You and Dr. Barnett return to Mrs. Saleh’s room, and he says, “It sounds like the past week or two have been really hard on you and your family.”
“Yes!” she exclaims. “I just want to feel better and have everyone healthy again.”
After confirming your history and examination, Dr. Barnett explains that just as her family is getting better, she will also likely feel better in a few days. In the meantime, she can continue to do those things that make her feel better, like taking a decongestant or saline nose spray for the congestion and acetaminophen for any fever or pain. She can continue drinking mint tea and using eucalyptus ointment on her chest if it makes her feel better.
You say goodbye to Mrs. Saleh and assure her that she can return if she is not feeling better in another week, or anytime if she starts to feel worse.
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Decongestant (such as pseudoephedrine) or saline nasal spray for congestion.
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Acetaminophen for fever and pain.
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Physicians frequently recommend pushing fluids, though a recent Cochrane review found no studies investigating this recommendation.
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Echinacea has not been consistently demonstrated to improve symptoms of the common cold.
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Vitamin C has shown mixed evidence in its ability to shorten the duration of the common cold. It may be worth a try for some patients, but it can cause kidney stones.
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Nasal ipratropium spray has been shown to slightly reduce rhinorrhea (runny nose) in the common cold, but not nasal congestion (stuffy nose).
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In outpatients at risk for progression to severe disease with mild to moderate COVID 19 not requiring supplemental oxygen, ritonavir-boosted nirmatrelvir (Paxlovid) and remdesivir are preferred therapy options because Phase 3 randomized placebo-controlled trials have reported high clinical efficacies for these agents. If ritonavir-boosted nirmatrelvir is not available or cannot be used because of drug interactions, use of remdesivir is recommended as the second option.
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AlBalawi ZH, Othman SS, Alfaleh K. Intranasal ipratropium bromide for the common cold. Cochrane Database Syst Rev. 2013;2013(6):CD008231. Published 2013 Jun 19.
Gottlieb RL, Nirula A, Chen P, et al. Effect of Bamlanivimab as Monotherapy or in Combination With Etesevimab on Viral Load in Patients With Mild to Moderate COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(7):632-44.
Guppy MP, Mickan SM, Del Mar CB, Thorning S, Rack A. Advising patients to increase fluid intake for treating acute respiratory infections. Cochrane Database Syst Rev. 2011;2011(2):CD004419. Published 2011 Feb 16.
Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2013;(1):CD000980. Published 2013 Jan 31.
Karsch-Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-Woelkart K, Linde K. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev. 2014;2(2):CD000530. Published 2014 Feb 20.
King D, Mitchell B, Williams CP, Spurling GK. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev. 2015;(4):CD006821. Published 2015 Apr 20.
NIH. COVID-19 Treatment Guidelines. Clinical Management. Nonhospitalized Adults: Therapeutic Management. Therapeutic Management of Nonhospitalized Adults With COVID-19. Last Updated April 8, 2022. Accessed May 4, 2022.
Two weeks later, Dr. Barnett tells you, “Mrs. Saleh is back in the office today. The nurses tell me she is feeling dizzy, which is one of the most common and yet challenging symptoms we encounter in family medicine.”
Dr. Barnett suggests that you consider the etiologies of dizziness before you go to obtain a more precise description of her dizziness from Mrs. Saleh.
A precise history is important in order to further differentiate between the potential etiologies of dizziness.
There are three categories to differentiate between when a patient presents with dizziness: presyncope, disequilibrium, and vertigo.
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Presyncope – Feeling light-headed or faint, as opposed to actually passing out. Sometimes patients with presyncope feel worse when they stand up quickly.
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Disequilibrium – A feeling of being off-balance.
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Vertigo – A sensation of the room spinning.
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Cardiac arrhythmias and some kinds of valvular heart disease like aortic stenosis can cause syncope (a temporary loss of consciousness, often described as “fainting” or “passing out”) and patients with new arrhythmias may experience dizziness.
Which of these patients might describe their dizziness as a feeling of lightheadedness or like they are going to faint?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. 26-year-old with thyroid storm
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B. 28-year-old with anemia secondary to acute bleeding from a gastric ulcer
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C. 36-year-old with aminoglycoside toxicity
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D. 48-year-old alcoholic with cerebellar degeneration
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E. 54-year-old with peripheral neuropathy
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F. 58-year-old with a myocardial infarction
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G. 68-year-old with atrial fibrillation and uncontrolled heart rate
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H. 72-year-old with acute gastroenteritis
The correct answers are A, B, F, G, H.
Dizziness that is described as “lightheaded” or “like I’m going to faint” is generally classified as presyncope and is usually caused by inadequate cerebral perfusion (A, B, F, G, and H). Treatment, therefore, is dependent on identifying and correcting the specific underlying cause.
Alcoholic cerebellar degeneration (D) is a cause of ataxia. Patients describe progressive weakness, lack of coordination, and unsteadiness of gait.
Aminoglycoside toxicity (C) usually causes symptoms of vertigo and hearing loss. Patients describe their dizziness as if the room is spinning.
Patients with peripheral neuropathy (E) have a loss of sensation and, particularly, positional sense. This causes patients to feel disequilibrium as if they have lost their balance.
Dizziness that is described as “lightheaded” or, “like I’m going to faint,” is generally classified as presyncope and is usually caused by inadequate cerebral perfusion. Treatment, therefore, is dependent on identifying and correcting the specific underlying cause.
All of the following conditions cause inadequate perfusion of the central nervous system via various mechanisms including:
|
Mechanism |
Condition |
Management |
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Inadequate cardiac output due to “pump failure” |
Myocardial infarction |
Rapid reperfusion with primary percutaneous coronary intervention is the goal if possible. Start with having patient chew an uncoated aspirin. See reference below for more details. |
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Inadequate cardiac output due to decreased filling time |
Atrial fibrillation |
Rate control in atrial fibrillation is achieved through pharmacologic or electric cardioversion or the use of calcium-channel blockers, beta-blockers, or digoxin if cardioversion is contraindicated or ineffective. |
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Inadequate cardiac output due to decreased filling time |
Tachycardia of thyroid storm |
Treatment of dizziness due to tachycardia caused by thyroid storm is focused on the treatment of the underlying hyperthyroidism and cardiac rate control with beta-blockers. |
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Inadequate cardiac output due to decreased heart rate |
Bradyarrhythmia |
Medications are a frequent cause of bradyarrhythmias, and treatment is simply withdrawal of the medication. Symptomatic bradyarrhythmias frequently require a pacemaker. |
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Inadequate cardiac output due to obstruction |
Valvular heart disease |
For example, aortic stenosis is a common valvular lesion in the elderly that may be asymptomatic; however, once syncope develops, valve replacement may be indicated. |
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Inadequate cardiac output due to decreased preload due to volume depletion |
Dehydration due to acute illness or volume loss from blood loss. |
Replacing volume and raising hemoglobin concentration are the mainstays of management. |
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Poor cerebral oxygenation due to inadequate hemoglobin concentration |
Acute blood loss such as gastric ulcer bleed |
Replacing acute blood loss via transfusion. |
Freeman RV, Otto CM. Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies. Circulation. 2005;111(24):3316-26.
Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39-viii.
Maarsingh OR, Dros J, Schellevis FG, et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med. 2010;8(3):196-205.
Neuhauser HK, Radtke A, von Brevern M, Lezius F, Feldmann M, Lempert T. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168(19):2118-24.
Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017;95(3):154-62.
Switaj TL, Christensen SR, Brewer DM. Acute Coronary Syndrome: Current Treatment. Am Fam Physician. 2017;95(4):232-40.
You enter the exam room and are surprised to see Mrs. Saleh is lying on the exam table with an emesis basin next to her.
You say, “Oh, I’m so sorry you aren’t feeling well.”
In response to your further questions, Mrs. Saleh tells you the dizziness is constant and not dependent on her position but does get worse when she moves her head.
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She has no fever and no headache.
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She has not noticed any change in hearing and has not had any tinnitus (a sensation of ringing, roaring, whistling, or other abnormal sound in the ear).
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She has no visual disturbance and no weakness, malaise, or numbness.
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She has no prior history of migraines or dizziness.
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You wonder if Mrs. Saleh’s vomiting could have caused enough dehydration to cause orthostatic hypotension, so you assess her vital signs in both supine and standing positions. You find the following results.
Orthostatic Vital Signs:
Supine: pulse is 88 beats per minute, blood pressure is 118/78 mmHg
Standing: pulse is 92 beats per minute, blood pressure is 114/72 mmHg
According to the consensus statement by the American Academy of Neurology and the American Autonomic Association, the definition of orthostatic hypotension is defined as either:
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A drop in systolic blood pressure of ≥ 20 mmHg or
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A drop in diastolic blood pressure of ≥ 10 mmHg
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When changing position from supine to standing
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There must be a gap of one to three minutes between transitioning to standing and measuring the vital signs
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Accompanied by feelings of dizziness or light-headedness
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Many people also consider a rise in the pulse by ≥ 20 BPM as a finding suggestive of orthostasis.
Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72.
Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39-viii.
You begin the eye exam by asking Mrs. Saleh to focus on a spot across the room. You don’t notice anything unusual until you move in front of her with the light—at which point she loses her focus. You find that you can hardly examine her retina because her eyes keep moving. On further examination, you notice that her eyes beat horizontally to the left when following your ophthalmoscope to the left. But if you ask Mrs. Saleh to fix her gaze to a point, the eye movements stop.
You continue the rest of your exam:
Head, eyes, ears, nose and throat (HEENT):
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Eyes: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Mild left horizontal nystagmus when following the ophthalmoscope to the left. The nystagmus stops when the gaze is on a fixed point.
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Fundi: Sharp optic disc margins.
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Ears: Hearing intact to finger rubbing. Weber is midline. Air conduction is greater than bone conduction bilaterally. Tympanic membranes are clear without opacification or effusions.
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Heart: Regular rate and rhythm. Normal S1, S2. No murmurs, clicks, or rubs.
Neurological exam: Cranial nerves: I – not tested. CN II-XII is normal with the exception of nystagmus as noted above. Motor exam: Strength 5/5 in all muscle groups. Sensory: intact to pain, light touch, position sense, vibratory sense. Reflexes: 2+ and symmetrical throughout. Coordination: finger-to-nose testing shows no dysmetria. Rapid alternating movements brisk. Heel-shin movements are precise. Gait: smooth, without shuffling or leg preference with eyes open. Falls to right with tandem gait and eyes closed. Romberg: Able to stand with eyes open. Falls to the right with eyes closed.
After completing the physical exam, you explain to Mrs. Saleh that you are going to talk to Dr. Barnett about everything you have found and will be right back.
Based on what you know about the patient so far, write a one-to-three sentence summary statement to communicate your understanding of the patient to other providers.
Your response is recorded in your student case report.
Letter Count: 37/1000
Mrs. Saleh is a 28-year-old with a recent upper respiratory infection who presents with acute onset, constant, non-positional vertigo with associated nausea and vomiting. On exam she has normal orthostatic vital signs, normal hearing, a positive Romberg test, and left horizontal nystagmus that resolves with gaze fixation and does not change with the direction of gaze.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
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Epidemiology and risk factors: 28-year-old with recent URI
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Key clinical findings about the present illness using qualifying adjectives and descriptive language:
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Acute onset vertigo
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Associated nausea and vomiting
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Normal orthostatic vital signs
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Normal hearing
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Positive Romberg test
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Left horizontal nystagmus that resolves with gaze fixation and does not change direction with gaze
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Dr. Barnett meets you in his office, and you present your history and physical exam findings, but add that you aren’t completely sure about your description of nystagmus and that you would like him to check that since you’ve never actually seen it before.
He responds: “Sure! We’ll look again together when we go back into the room.”
Dr. Barnett then asks you to consider a differential diagnosis for Mrs. Saleh’s dizziness based on your findings from her history and physical exam.
From the following, select the top three diagnoses on your differential.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Anemia
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B. Anxiety
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C. Benign paroxysmal positional vertigo (BPPV)
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D. Cardiac arrhythmia
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E. Cerebellar infarct
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F. Labyrinthitis
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G. Meniere’s disease
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H. Orthostatic hypotension
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I. Transient ischemic attack (TIA)
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J. Vestibular migraine
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K. Vestibular neuritis
The correct answers are C, F, K.
You realize that her asymmetric nystagmus finding likely indicates that she has a peripheral lesion, (see chart below). This makes central problems such as anxiety (B), cerebellar infarct (E), TIA (I), and vestibular migraine (J) less likely.
Orthostasis (H) has been ruled out in Mrs. Saleh’s case by her normal orthostatic vital signs.
Cardiac arrhythmia (D) typically causes dizziness and presyncope rather than the sensation of vertigo, which Mrs. Saleh has.
Peripheral causes of vertigo include BPPV (C), Meniere’s disease (G), Labyrinthitis (F), and vestibular neuritis (K). Of these, Meniere’s disease is less likely because it causes recurrent episodes of vertigo associated with unilateral hearing loss, a sensation of fullness in the ear and tinnitus.
Most Likely Diagnoses
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Vestibular neuritis |
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Acute labyrinthitis |
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Benign paroxysmal positional vertigo (BPPV) |
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Vestibular migraine |
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Peripheral versus Central Vertigo
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Peripheral |
Central |
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Location of pathology |
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Nystagmus |
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Less Likely Diagnoses
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Anemia |
Usually presyncopal in nature and described as lightheadedness. Not associated with nystagmus. |
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Anxiety |
Anxiety can occasionally present with dizziness, but the dizzy sensation is usually vaguely described and also would not be associated with nystagmus. |
|
Cardiac arrhythmias |
Cardiac arrhythmias are an important cause of dizziness, especially in patients at risk for cardiac disease. Bradyarrhythmias, atrial fibrillation, atrial flutter, heart block, and tachyarrhythmias are all potential causes of presyncope. Although evidence suggests that in elderly patients, cardiac etiologies of dizziness and even vertigo are common, cardiac etiologies are not common in younger age groups without any cardiac risk factors and with a normal cardiac exam. In addition, cardiac etiologies of dizziness would not present with nystagmus. |
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Cerebellar infarct |
Cerebellar infarct is an uncommon cause of vertigo and is more often characterized as disequilibrium. Nystagmus that resolves with gaze fixation is characteristic of peripheral rather than central causes of vertigo and speaks strongly against this diagnosis. In addition, patients with a cerebellar infarct will usually demonstrate neurologic findings localized to the cerebellum, such as severe ataxia and/or dysmetria. |
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Meniere’s disease |
Episodes lasting 20 minutes to 24 hours of unilateral hearing loss, tinnitus, and vertigo form the classic triad of Meniere’s disease. Thought to be due to increased fluid in the chambers of the inner ear. |
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Orthostatic hypotension |
Orthostatic hypotension can cause dizziness that seems positional since it occurs upon sitting or standing up suddenly. Orthostatic hypotension occurs as a result of volume loss in the intravascular space, such as with dehydration or acute blood loss. |
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Otitis media |
Otitis media can occasionally be a cause of vertigo. After a recent upper respiratory infection, otitis media is a possibility; however, patients with otitis media usually have ear pain and an abnormal ear exam. Fever also commonly accompanies otitis media. |
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Transient ischemic attack (TIA) |
Transient ischemic attack (TIA) can cause symptoms of vertigo, but these should not be constant. |
Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39-viii.
Maarsingh OR, Dros J, Schellevis FG, et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med. 2010;8(3):196-205.
Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017;95(3):154-62.
Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183(9):E571-E592.
You decide the most likely explanation at this point is vestibular neuritis or acute labyrinthitis, especially given that Mrs. Saleh has constant symptoms of vertigo, unrelated to position, with signs of a peripheral lesion, and an otherwise normal neurological exam, and symptoms that occurred shortly after a viral upper respiratory infection.
Dr. Barnett praises your clinical reasoning, “I agree it certainly sounds like vestibular neuritis.”
He teaches you, “An even more common cause of vertigo seen in primary care practice is benign positional vertigo—but with no history of positional vertigo, BPPV is not likely in this case.” Dr. Barnett explains how to diagnose BPPV in a patient with a typical history of this.
1. Most common cause:
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Benign paroxysmal positional vertigo (BPPV)
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2. Second-most common causes:
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Vestibular neuritis results when a viral (or, less commonly, bacterial) infection of the inner ear causes inflammation of the vestibular branch of the eighth cranial nerve.
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Acute labyrinthitis occurs when an infection affects both branches of the eighth cranial nerve resulting in tinnitus and/or hearing loss as well as vertigo.
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One way to confirm the diagnosis of BPPV is the Dix-Hallpike testing and example of nystagmus (video).
Turn the patient’s head to 45 degrees and quickly lay him down supine with his head just over the end of the exam table. Then turn the head to the side which should reproduce the symptoms of dizziness and produce nystagmus. Observe for 20 to 30 seconds. If present, nystagmus will have the fast component in the direction of the pathology. Next, sit the patient up and observe again for nystagmus.
You wonder, “Is there any way to tell for sure that Mrs. Saleh has vestibular neuritis? Would neuroimaging be useful?”
“Actually, both BPPV and vestibular neuritis are clinical diagnoses based on characteristic findings in the history and physical,” Dr. Barnett informs you.
“You are absolutely right, though. We would not want to miss a potentially life-threatening cause of vertigo-like a cerebellar infarct or a TIA,” he affirms. “So if there is any suggestion of a central lesion, we would do further testing. Magnetic resonance imaging (MRI) is the test of choice.”
Observation of nystagmus is essential to differentiate between peripheral and central vertigo. The head thrust test (sometimes called the head impulse test) is used to demonstrate a likely peripheral lesion.
Normally, when you face your patient and ask them to keep looking at your nose, their eyes will stay fixed on your nose if you move their head suddenly to the side. If there is a peripheral lesion in the vestibular system, the vestibular ocular reflex will be disrupted, and the patient’s eyes will move with the head and then saccade back to center when their head is moved in the direction of the lesion. The meaning of saccade is a small rapid jerky movement of the eye especially as it jumps from fixation on one point to another (as in reading). A normal head thrust test in the presence of vertigo means the peripheral vestibular system is intact and that the lesion is central.
Which of the following patients with vertigo would require neurologic imaging?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. A 28-year-old healthy patient with new-onset constant vertigo with no other neurologic symptoms. On physical exam, they have unidirectional nystagmus that disappears when their gaze is fixed.
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B. A 40-year-old with a history of migraines and new-onset headache with constant, non-positional vertigo. Their head thrust test displays a normal response.
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C. A 45-year-old with recurrent episodes of brief intense vertigo every time he turns his head rapidly. They have no other neurologic signs or symptoms. They have a positive Dix-Hallpike maneuver.
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D. A 66-year-old with recurrent episodes of vertigo associated with tinnitus and hearing loss. Their head thrust test is positive with saccade back to center when their head is thrust to the right.
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E. A 68-year-old with a history of hypertension and sudden acute onset of constant vertigo. They have right-beating nystagmus that changes direction with gaze and that does not disappear when they focus.
The correct answers are B, E.
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Option |
Imaging Needed? |
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A |
No |
Unidirectional nystagmus that disappears with fixation and recurs with loss of fixation implies a peripheral lesion. In the absence of other neurological signs and symptoms in an otherwise well, young patient, neuroimaging is not needed since the likelihood of a central lesion is minimal. |
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B |
Yes |
A normal head thrust test in the face of constant and new vertigo combined with a history of migraines indicates a possible central lesion. Neuroimaging is needed. |
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C |
No |
This patient has a classic history of benign paroxysmal positional vertigo (BPPV). In addition, the positive Dix-Hallpike maneuver confirms the diagnosis. Neuroimaging is not required. |
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D |
No |
The triad of recurrent episodes of vertigo, tinnitus, and hearing loss is characteristic of Meniere’s disease, which is a peripheral lesion. A positive head thrust test reassures that the lesion is peripheral. |
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E |
Yes |
There are multiple reasons to be concerned about a central lesion and possible infarct in this patient. Their age puts them at risk as does hypertension. Physical exam shows nystagmus that changes direction, and that does not inhibit with focus. Both of these findings are consistent with a central lesion. This patient needs an urgent MRI. |
Neuroimaging (MRI) is required for patients with vertigo if there is a suggestion of a central lesion. The most common causes of vertigo are peripheral, so usually imaging is not required. Patients with symptoms suggestive of stroke or acute TIA require urgent neuroimaging in an emergency department. Patients whose physical examinations reveal findings of central origin (persistent nystagmus with fixed gaze, normal head thrust test) should also undergo imaging.
Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017;95(3):154-62.
You and Dr. Barnett return to see Mrs. Saleh. You find her lying on the examination table with her head very still. Dr. Barnett elicits pertinent history, performs a focused physical exam, and agrees with your findings.
Mrs. Saleh has left-beating horizontal nystagmus that disappears when she fixes on a focal point and recurs when she loses the focal point.
Head thrust test is positive. (Saccade (fast shift of the eye) back to the center.)
Dr. Barnett explains his findings to Mrs. Saleh and lets her know that because her history and physical exam are so typical of acute vestibular neuritis, she will not need further testing at this time, concluding, “Your symptoms should improve over the next couple of days to a week.”
Mrs. Saleh asks, “What about this dizziness and the nausea? Is there anything to make it go away?”
Which of the following are appropriate therapeutic choices for a patient with peripheral vertigo (BPPV, Menieres, labrynthitis, vestibular neuritis)?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Antimicrobial agents
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B. Diuretics
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C. Epley maneuvers
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D. Vestibular rehabilitation exercises
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E. Vestibular suppressant medications
The correct answers are B, C, D, E.
Diuretics and a low salt diet are commonly used to treat the vertigo of Menière’s disease following the reasoning that the use of diuretics will decrease the endolymphatic pressure and abate symptoms. A 2006 Cochrane review noted that there were “no trials of high enough quality” to allow a recommendation for or against the use of diuretics in the treatment of Menière’s disease or other causes of vertigo.
The Epley maneuver, or canalith repositioning, is the hallmark of treatment for BPPV. The etiology of vertigo in BPPV is the presence of calcium debris in the semicircular canals. Through careful positioning of the patient, the Epley maneuver relieves symptoms by returning the deposits back to the vestibule. The maneuver can be performed in the clinic and modified by the patient at home. To perform the Epley maneuver for right-sided symptoms, the patient sits on the exam table with his head turned 45 degrees to the right. With the clinician supporting the head, the patient quickly lies back with his head hanging over the exam table supported by the clinician as in the Dix-Hallpike test. Once the nystagmus has stopped, the clinician turns the head 90 degrees to the left, and the position is held for 30 seconds. Next, the patient rolls onto his left side, with his face at a 45-degree angle to the floor. This position is held for 30 more seconds. The patient returns to the sitting position now with his legs off the left edge of the table. After another 30 seconds, the patient can resume normal head position. The maneuver can also be repeated on the other side. Repositioning maneuvers are not effective for the treatment of vertigo not caused by canalith debris.
A Cochrane review found “There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high quality randomized controlled trials.” Patients can be trained in vestibular rehabilitation by a physical therapist.
Vestibular suppressant medications can be an effective short-term treatment of vertigo. Commonly used anticholinergic vestibular suppressants such as meclizine and dimenhydrinate also have some antiemetic effects that are useful in controlling the nausea and vomiting associated with vertigo. Antiemetics can be a useful adjunct in select patients. Non-selective phenothiazine antiemetics, such as metoclopramide and promethazine, can be effective. Since all these medications can also cause sedation, they should be used acutely only and avoided in the elderly. Antiemetics and antinausea medications should be used for no more than three days because of their effects in blocking central compensation, which may slow recovery.
Except in the case of vertigo secondary to otitis media, antimicrobials are not useful in the treatment of vertigo.
Thirlwall AS, Kundu S. Diuretics for Ménière’s disease or syndrome. Cochrane Database Syst Rev. 2006;(3):CD003599. Published 2006 Jul 19.
Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2011;(2):CD005397. Published 2011 Feb 16.
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162. Published 2014 Dec 8.
Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017;95(3):154-62.
Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005;71(6):1115-22.
“There are some medications that may help you feel better,” Dr. Barnett reassures her. “However, as with all medications there could be some side effects we need to talk about so you can make a good choice about taking them. The two types of medications I am thinking of will help with the nausea and dizziness, but both can cause some sedation so you might be a little more sleepy. Also, I know you are still breastfeeding, so that is something to consider as well.”
“I would never want to take anything that might hurt my baby!” Mrs. Saleh tells you.
Dr. Barnett accesses the LactMed database on his smartphone and the three of you together search for meclizine and promethazine.
After you help Mrs. Saleh interpret the language she decides, “It sounds like they are pretty safe for my baby but still, I can’t afford to be sleepy and I don’t want to take any chances with breastfeeding. Since you told me I would probably start feeling better pretty soon, I think I will just try and tough it out. But can I have a prescription just in case I need it?”
“Sure,” Dr. Barnett tells her. “If you do take the medicine, stop as soon as you are feeling better. We will also give you some exercises to do to help your body adjust to the dizziness. And we will call you in a couple of days to make sure you are getting better. Of course, if you start feeling worse, come back before then.”
Two days later you call Mrs. Saleh. She is pleased that you have made the effort to follow up with her. She reports that she is still a little dizzy, but the nausea is gone and she is feeling much better. You remind her to start her exercises and make an appointment for a return visit in a few weeks for her annual health maintenance exam.
The LactMed database states:
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“Occasional doses of meclizine are probably acceptable during breastfeeding. Large doses or more prolonged use may cause effects in the infant or decrease the milk supply…”
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“Based on minimal excretion of other phenothiazine derivatives, it appears that occasional short-term use of promethazine for the treatment of nausea and vomiting poses little risk to the breastfed infant. With repeated doses, observe infants for excess sedation.”
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NIH. National Library of Medicine: National Center for Biotechnology Information. Bookshelf. Drugs and Lactation Database (LactMed®). https://www.ncbi.nlm.nih.gov/books/NBK501922/?report=classic. Accessed June 3, 2022.
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Updated Learning Objectives to align them more closely with the STFM National Clerkship Curriculum.
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Updated content regarding testing criteria for COVID-19.
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Updated preferred outpatient treatment options for COVID-19, removed monoclonal antibodies, and added ritonavir-boosted nirmatrelvir (Paxlovid) and Remdesivir as preferred options.
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Updated references.
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The student should be able to:
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Identify common causes of upper respiratory infections in adults.
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Discuss appropriate use of antibiotics in the treatment of upper respiratory infections.
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Counsel patients regarding appropriate therapeutic measures for upper respiratory infections.
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Employ effective and empathic strategies for communicating with patients and families.
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Identify the common causes and treatment options for vertigo, presyncope, and disequilibrium.
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Describe history and physical characteristics that correlate with different causes of dizziness.
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Discuss specific exam maneuvers and the significance of physical exam findings for the diagnosis of vertigo.
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Identify signs and symptoms of dizziness that may indicate serious disease.
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Discuss the importance of a cost-effective approach to the diagnostic work-up of dizziness including the role of neuroimaging.
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Formulate cause-specific treatment for common causes of vertigo.
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Describe the initial management of common and dangerous diagnoses that present with a particular symptom.
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Demonstrate interpersonal and communication skills that result in effective information exchange between patients of all ages and their families.
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Differentiate among common etiologies that cause dizziness based on the presenting symptoms.
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Recognize “don’t miss” conditions that may present with dizziness.
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Mr. Jones is a 67-year-old male brought into your office because he has been having “dizzy spells and room spinning” for the past two days that are intermittent. Your records indicate a history of back pain, diabetes, and hypertension. Upon further questioning, Mr. Jones cannot identify when these spells come on and nothing seems to relieve them. His temperature is 37 °C (98.6 °F); blood pressure is 165/95 mmHg; pulse is 78 beats/minute; respiratory rate is 18 breaths/minute. On physical exam, you notice a slight nystagmus. You ask him to focus on your nose, but the nystagmus continues.
What is the most likely cause of his “dizzy spells”?
- A. Anemia
- B. Bleeding gastric ulcer
- C. Hyperthyroidism with thyroid storm
- D. Stroke
- E. Vestibular neuritis
You are seeing a 54-year-old female with a past medical history of kidney stones who presents with a chief complaint of “I have a terrible summer cold.” She reports three days of low-grade fevers (peak of 100.0 °F), cough, sore throat, headaches, and nasal congestion. She reports no myalgia. Her temperature today is 37.3 °C (99.2 °F), respiration is 14/minute, pulse is 78 beats/minute, and blood pressure is 128/74 mmHg. Her head and neck exam reveal normal tympanic membranes, mildly congested nasal turbinates with thin mucous, erythema of the tonsillar pillars, and soft palate without tonsillar enlargement or exudate, and mild anterior cervical lymphadenopathy. Her lungs are clear to auscultation.
Assuming that COVID-19 is not a consideration, which of the following options would be the most appropriate therapeutic option for this patient?
- A. Echinacea supplementation
- B. Oseltamivir (Tamiflu) 75 mg twice daily for five days
- C. Pseudoephedrine (Sudafed) as needed for nasal congestion
- D. Vitamin C supplementation
- E. Zinc supplementation
You are seeing a 60-year-old male brought into your office because of “dizzy spells where he almost passes out” for a week. Your records indicate a history of back pain and diabetes. Upon further questioning, he says he sometimes feels like he is going to pass out and gets short of breath after walking about half a block. He’s never felt this way before. He reports not having a spinning sensation when he is dizzy. His back has also been really bothering him for the past several weeks so he has been taking ibuprofen “all the time.” His temperature is 37 °C (98.6 °F); blood pressure is 105/65 mmHg; pulse is 100 beats/minute; respiratory rate is 18 breaths/minute. On physical exam, you note no nystagmus, but he does have conjunctival pallor. His lungs are clear to auscultation, and his cardiac exam reveals mild tachycardia with a regular rate and no murmurs. His abdomen is mildly tender and non-distended.
As you think through your differential diagnosis and tests to order, which of the following best describes the likely etiology of his symptoms?
- A. Acute labyrinthitis
- B. Anemia
- C. Aortic stenosis
- D. Myocardial infarction
- E. Thyroid storm
You are seeing a 35-year-old female with no past medical history who presents with dizziness for the past week. She says these episodes of dizziness in which the room feels as though it is spinning, last for a minute or two at most, but she cannot seem to identify what is causing them. She reports no change in diet, headaches, or recent illness. Her father passed away from a stroke at the age of 60, but she reports no other significant family medical history. Her vital signs are all normal, as is her head and neck exam. Her lungs are clear to auscultation bilaterally, and her cardiac exam reveals a regular rate and rhythm with no murmurs. You are able to elicit saccades with a head thrust maneuver. You perform a Dix-Hallpike maneuver, which elicits her symptoms and causes rotary nystagmus when she looks to the right.
What is the most appropriate next step?
- A. Cardiac enzymes
- B. ECG
- C. Emergency CT scan
- D. Emergency MRI scan
- E. Epley maneuver
An otherwise healthy 58-year-old female presents in your office with a cough, sore throat, and fevers for the past five days.
Which of the following clinical details would lead you to treat with an antibacterial agent?
- A. Dullness to percussion and crackles on lung exam, consistent with community-acquired pneumonia
- B. Myalgias consistent with influenza
- C. Non-erythematous tympanic membrane with clear effusion
- D. Purulent discharge and sinus tenderness consistent with acute sinusitis
- E. Wheezing and productive cough consistent with acute bronchitis
Thank you for completing Family Medicine 33: 28-year-old female with dizziness.
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Answer Comment
The correct answers are A, E, F.
Deciding Whether to Use Antibiotic Treatment for Uncomplicated Respiratory Tract or Ear Infections
Uncomplicated otitis media
The majority of cases of uncomplicated otitis media are viral in origin. According to American Academy of Pediatrics and American Academy of Family Physicians guidelines, children over two years old with uncomplicated acute otitis media may be treated with additional observation without prescribing antibiotics; children less than six months should be treated with antibiotics; and those between six months and two years old with uncomplicated unilateral otitis media may be cautiously observed first—depending on the certainty of the diagnosis, social support, and clinical picture. Furthermore, the Choosing Wisely Campaign for family medicine included a recommendation that clinicians do not prescribe antibiotics for children with non-severe otitis media who are aged 2 to 12 when observation for 48 to 72 hours is reasonable.
Community-acquired pneumonia
Community-acquired pneumonia should be treated with antibiotics.
Streptococcal pharyngitis
Streptococcal pharyngitis should be treated with antibiotics to prevent complications and to shorten the course of disease. Penicillin is the treatment of choice.
Maxillary sinusitis
Maxillary sinusitis is usually preceded by an upper respiratory infection. Signs and symptoms include facial pain in the area of the maxillary sinuses, purulent nasal discharge, postnasal drip, and tenderness to palpation or percussion of the sinuses. A recent Cochrane review concluded that in otherwise uncomplicated maxillary sinusitis, the beneficial effect of antibiotics is minimal and does not justify the use. This systematic review excluded studies of sinusitis complicated by involvement of multiple sinuses, severe systemic signs and symptoms, acute isolated frontal sinusitis, recurrent sinusitis, or sinusitis with known anatomic defect. Additionally, the Choosing Wisely Campaign recommendations for family medicine include recommending physicians not prescribe antibiotics for sinusitis unless symptoms have lasted more than 10 days or there is double worsening (symptoms start to resolve, then get suddenly worse).
Viral upper respiratory infections
Treatment of viral upper respiratory infections with antibiotics does not improve prognosis or decrease the length of illness.
Bronchitis
Whether or not to treat bronchitis with antibiotics is less clear, as antibiotics can have a modest effect on the length and severity of symptoms in acute bronchitis. However, most people will recover without antibiotic treatment. The increasing resistance patterns favor a watchful waiting approach in the treatment of otherwise healthy individuals with acute bronchitis.