Primary Care Teaching Module: Weakness and Dizziness

Douglas B. Fridsma, M.D.

Stanford University Division of General Internal Medicine

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A. Learning Objectives

B. Clinical Scenarios

Case 1:

A 57 year old man with a history of hypertension and elevated cholesterol, presents to the clinic with the 1 day onset of dizziness, nausea, vomiting, and weakness. When you enter the room, the patient is lying on the table already, and when he sits up he again feels lightheadedness, nausea, and the sensation that "the room is spinning". After a few minutes of sitting still, his symptoms subjectively improve. The Nylen-Barany test is positive, his resting pulse of 95, rises to 110 when he sits up. BP lying is 140/85 supine, 130/70 with sitting. The remainder of the exam is normal.

Questions:

  1. Describe the Nylen-Barany test. What is its utility in formulating the differential diagnosis?
  2. What are possible diagnoses? What is most likely?
  3. What features that would indicate a serious cause of dizziness? Does this patient have these features?
  4. How might you manage this patient?

Case 2:

A 78 year old Haitian women with a history of congestive heart disease, arthritis, hypertension, bilateral cataracts, and long-standing type II diabetes complains of weakness and dizziness. She denies nausea and vomiting, and states the dizziness is worse at in the evenings. She finds it difficult to characterize her dizziness, and feels that the room is spinning, sometimes feels like she might faint, but she has never lost consciousness. She has become nearly house bound in the past few months because of her sensation of dizziness and the fear that she might fall or faint. Medications include HCTZ, digoxin, captopril, Desyrelreg., and motrin for arthritis. On exam, her BP is 130/70 lying and 120/65 when sitting, and she is unsteady on her feet when going from the chair to the examination table. Nylen-Barany test is difficult to perform because she keeps closing her eyes. She has decreased sensation in her lower extremities to pinprick and her romberg test is positive.

Questions:

  1. What are some possible reasons for the symptoms of dizziness and weakness in this patient?
  2. If the patient had been having some new symptoms of urinary retention and constipation, how might that change your evaluation?
  3. Is the patient's cultural background relevant?
  4. How might you manage this patient?

Case 3:

A 36 year old women complains of dizziness and lightheadedness that has been persistent for years. The dizziness is present when she gets up is worse with upright posture, relieved with lying down. She has had multiple visits to the doctor's office for many different complaints, but rarely has been able to find a diagnosis to explain her symptoms. Nylen-Barany test is negative, but hyperventilation for 3 minutes reproduces her symptoms.

Questions:

  1. What tests would be appropriate for the evaluation for this patient?
  2. How might you manage this patient?
  3. What are the risks to conservative therapy?

Case 4:

A 70 year old man with a history of HTN, heart disease, diabetes and hypercholesterolemia comes in with episodes of dizziness and weakness over the past 3 months. The patient describes these episodes as feeling lightheaded and loss of energy and occurring at unpredictable times. Most of the episodes only lasted a few minutes, but he comes into the clinic today after an episode of dizziness and feeling weak that lasted over 30 minutes. He has never fainted, but felt like me might pass out. On physical exam, BP 170/94, a right carotid bruit is present. The heart exam shows a PMI that is laterally displaced, with occasional PVC.

Questions:

  1. What do you think is the cause of this man's symptoms?
  2. How might you evaluate this patient?

C. Main Teaching Points

D. Expanded Discussion for the Facilitator

Case 1:

The Nylen-Barany test can help to differentiate the presence of nystagmus as well as peripheral vs. central causes of the nystagmus. In some studies, when the NB test is positive and associated with vomiting and vertigo, the MB test had a specificity of 94% and sensitivity of 43%.

The Nylen-Barany test is performed with the patient initially sitting on the examination table with the physician behind the patient. (A picture in the JAMA article (p.386) included with these case studies describes the test more clearly). Quickly the patient is brought into the lying position with they head slightly hyper extended over the end of the table. The patient should be given clear instructions to keep the eyes open. The patient is then observed for signs of nystagmus. If nystagmus is present, but extinguishable, then it is more likely to be a peripheral cause. If it is persistent, suspect a central cause.

In this case, the patient has at least 2 causes for his dizziness: orthostatic changes from nausea and vomiting, and a probable labyrinthitis. Given the time course he describes, it is likely that the labyrinthitis preceded his orthostatic complaints. Careful examination of the ears for cholesteatoma, and otitis media is warranted, and examination of the sinus and through for sinusitis and URI symptoms will be important to rule out diseases that might require antibiotics.

In general, labyrinthitis is self-limited and will resolve with symptomatic care. This would include meclizine (Antivertreg.) at 25 mg tid for dizziness and Compazinereg. for nausea. Bedrest will avoid exacerbating the symptoms.

If his symptoms where accompanied by hearing loss, nystagmus that did not extinguish, this would indicate a more serious cause of dizziness such as Meniere's disease or a central cause (tumor, basilar insufficiency, CVA, TIA)

It is important to realize that if these more serious signs are not present, it is safe to treat the patient presumptively and conservatively with close follow-up.

Case 2:

In patients over 75 years, dizziness is the most common presenting complain to general practitioners.

In the elderly as with this patient, the causes of dizziness are most often multifactorial, though this patient's symptoms might best be characterized by dysequilibrium than vertigo. Possible causes include peripheral neuropathy with impaired proprioception and polypharmacy with drugs that have orthostatic side-effects. With peripheral neuropathy, these symptoms are worse at night, when the patient is unable to use vision to compensate for their proprioceptive or vestibular losses. Renal disease or diabetes often have peripheral neuropathy that will predispose patients to impaired proprioception.

Other factors to consider are medications -- this patient is on 2 anti-hypertensive medications as well as trazadone (Desyrelreg.) that has significant orthostatic side-effects. In some studies, over 20% of patients with dizziness, the symptoms could be attributed to medications.

If the patient had recent bladder dysfunction, weakness or numbness, cervical stenosis should be considered. This patient has long-standing arthritis that may increase her risk for cervical disease.

It is important to treat these symptoms with the elderly since the sensation of dysequilibrium can lead to increased isolation, depression and falls in the elderly, significant causes of morbidity and mortality in the elderly.

The "weak and dizzies" often have an ethnomedical aspect to them. In many cultures, the vague somatic complaints of "weak and dizzies" are a popular idiom for emotional distress. In the Haitian culture, "weak and dizzies" is associated with too much "worriation" in one's life, resulting in a general decline in strength and clinical depression.

Case 3:

"Weak and Dizzy" is often times associated with depression and somatization disorder, particularly in patients that have no physical examination findings. A test that can help to suggest the diagnosis is having the patient hyperventilate for 3 minutes: if this reproduces the symptoms, anxiety or depression can be considered more strongly. Risk factors for psychiatric etiology of dizziness include age less than 40, complaints of weakness, headaches and dizziness provoked by hyperventilation. In one study at a military hospital, 40% of patients with weakness and dizziness had an underlying psychiatric diagnosis. Extensive testing in these situations would be inappropriate.

Though it can be difficult to be certain that serious causes of disease have been appropriately evaluated, it is important to recognize that conservative therapy of patients with complaints of dizziness is not associated with high mortality. In a study looking at the management of dizziness in primary care, patients were treated with a combination of different therapies, but most (71%) where treated with observation, and not significant complications occurred because of delays in diagnosis. The accompanying JAMA article includes some ways of distinguishing serious from benign causes of dizziness, and the second article describes the outcomes with patients that present with dizziness. In most circumstances, conservative management was appropriate.

Case 4:

Patients with underlying heart disease and an abnormal heart exam are more likely to have a cardiac etiology. In this patient, there is also evidence of vascular disease. It is unlikely that the carotid bruit will explain his symptoms, but if there is evidence of carotid disease, there may be basilar insufficiency. Most likely however, is that the patient is having cardiac arrhythmias that are causing episodes of lightheadedness and weakness from poor peripheral perfusion. This patient will likely require some additional testing with outpatient cardiac holter monitoring, or referral to subspecialist.

E. Annotated Bibliography

Baloh RW, "Dizziness in Older People", Journal of American Geriatrics Society, 40:7, July 1992, p. 713-721.

This article provides a multi-factorial approach to dizziness in the elderly, with logic flow charts on how to diagnose the most common causes of dizziness in the elderly, and includes some causes that are specific to the elderly -- decreased proprioception and senile gate-- that are not well covered in other reviews.

Froehling DA, et. al., "Does This Dizzy Patient Have a Serious Form of Vertigo?" Journal of America Medical Association, 271:5, Feb. 2, 1994. p. 385-388.

A nice brief article looking at what factors would prompt further evaluation and a nice review of the practical clinical and history signs to look for in a patient with the complaint of dizziness.

Hanson MR, "The Dizzy Patient: A Practical Approach to Management" , postgraduate Medicine 85:2, February 1, 1989.

This article gives the pneumonic SNOOP (systemic, neurologic, otologic, ophthalmalogic, psychogenic) as a way to remember the causes of dizziness.

Herr R, Zun L, Mathews J, "A Directed Approach to the Dizzy Patient" , Annals of Emergency Medicine,18:6 Jun 1989, p .664-672.

This study was based in the emergency room, and its results taken in that light. It found that the Nylen-Barany test was the most predictive of vestibular disease, the most common cause of dizziness. Older age, neurologic abnormalities and the absence of vertigo predicted more serious forms of dizziness, although there is no mention of the psychiatric or medication-induced forms of dizziness.

Kroenke K, et al., "Psychiatric Disorders and Functional Impairment in Patients with Persistent Dizziness," Journal of General Internal Medicine 8:10 October, 1993, p. 530-535.

This article found that 40% of the patients surveyed in outpatient clinics at a military outpatient clinic had a psychiatric diagnosis as a principle cause or contributing factor to the dizziness symptoms.

Linstrom CJ, "Office Management of the Dizzy Patient", Otolaryngologic Clinics of North America, 24:4, August 1992.

Written by otolaryngologists, this paper focuses on the more uncommon causes of dizziness, and management of more serious causes of dizziness.

Nations M, et all, "`Hidden' Popular Illnesses in Primary Care: Residents' Recognition and Clinical Implications", Culture Medicine and Psychiatry ,9:(1985), p. 223-240.

An interesting article looking at the social and ethic factors that affect the way in which particular diseases present.

Sloane PD, et. al., "Management of Dizziness in Primary Care", Journal of American Board of Family Practice, &:1, Jan-Feb. 1994, p. 1-8.

This article is more description than prescriptive, but gives a good overview about how general internist and primary care physicians treat patients with dizziness. The bottom line -- a conscientious, conservative course of action is probably best.

Skiendzielewski JJ, "The Weak and Dizzy Patient", Annals of Emergency Medicine, (:7, July 1980, p 353-356.

This paper suggest that age over 60 is associated with more serious causes of dizziness than in the younger patients, though 20% of these patients, the dizziness was related to medication. In the serious category, the top three diagnosis are medication-induced(22%), Labaryrinthine vertigo(16%), and `dizziness of unknown etiology'(11%).