#dxerror

   Jennifer Derebery, MD    Associate at House Ear Clinic, Inc    Clinical Professor, Department of Otolaryngology at the University of Southern          California School of Medicine 

Though dizziness symptoms are common, I consider diagnosing the cause challenging due to the complexity of their possible origins. When diagnosing dizziness, I like to use the “three-legged stool” approach that places the brain as the master center of balance or the seat of the stool; with the three legs supporting the seat refer to the dizziness’ origin. The three legs are as labeled:

Vestibular System – The sensory mechanism in the inner ear that detects movement of the head and helps to control balance

Proprioceptive System – The sensory receptors that are found in the skin, muscles and joints that are sensitive to stretch or pressure in the surrounding tissues

Visual System – The sensory receptors in the retina when affected send impulses to the brain that provide visual cues identifying how a person is relative to the other objects they are looking at

Using the “Three-Legged Stool” approach to pinpoint the high level sources of the dizziness, you can begin to refine your original diagnosis. I also, outlined three types of differential diagnosis:

Peripheral – Inner Ear

Central – The Brain

Systemic – Leading to a symptom                             

After going through the basics, make sure to incorporate the patient in the diagnosis.  It is essential to make the patient feel like they are contributing to their own diagnosis, so make it a point to ask the patient two important questions when diagnosing dizziness: 

What the patient means by dizziness

Does the patient feel they are “spinning,” as with vertigo?

Do they feel “drunk” or imbalanced?

Timing of dizziness-  Depending on the time frame, diagnosing the cause of dizziness can vary

Seconds of dizzy sensations could indicate benign positional vertigo

Minutes of dizziness could indicate a circulatory problem

Hours of dizziness could indicate Meniere’s or migraine

Days of dizziness could indicate viral labyrinthitis, and probably excludes the possibility of an inner ear problem

Constant dizziness probably does not indicate a primarily otolaryngological disorder

Whether the patient is experiencing  hearing loss problems in one half of the inner ear can often affect the other

The pattern of the hearing loss can also offer clues to inner ear problems

Presence of hearing loss symptoms, plus the timing of the dizziness, are two strong indicators in the source of dizziness

The severity of the diagnosis can be quickly made through a proper imaging study and physical examination. Determining whether it is a hemorrhage or a central nervous system problem can be accomplished with a simple exam or imaging study.

Recurring symptoms of benign positional vertigo can often indicate migraine. Keys indications are headaches or other forms of head discomfort, but also can include motion-induced dizziness such as spinning or imbalanced sensations, even if they haven’t experienced these symptoms in several years. Ask the patient whether they are bothered by light or loud sound: these symptoms would also indicate possible migraine. For treatment options, watch Diagnosing Dizziness: Tips for the Primary Care Doctor.

 Alice Ackerman, MD   Founding Chair  Department of Pediatrics  Virginia Tech Carilion School of Medicine

Reposted with permission from Dr. Ackerman's blog. 

The Myth

There should always be ONE right answer to any problem in medicine. Patients should be able to seek advice from a qualified physician about their symptoms and get an answer. If they present the next doctor with the same symptoms he or she should offer the same advice as the first.

The Reality

Most physicians, especially the experienced ones, know that for many patients, ONE right answer isn't necessarily clear. That’s when it becomes important to be a physician who can say "I don't know,” and help find the right answer for the patient and their family. None of us can know everything. But we can strive to be certain that we know what we don't know, so we don't get caught up in making assumptions, and jumping to conclusions. Or, worse yet, telling patients that the symptoms they report in themselves or their child are not real, because they don't meet our expectations.

I have been impressed (not favorably) that many physicians, faced with a child or adult with a perplexing illness, or set of symptoms, will tell the parents, after a sequence of negative or unrevealing tests: "there is nothing wrong", or "there is nothing I can do for you." While the latter may be true, is that where the physician's responsibility ends? I am much more favorably inclined toward my colleagues who say: " I don't know the answer, so I am going to consult with colleagues around the country", or "I am going to refer you to someone who is a super specialist in this area", or who will help you to get an appointment with someone you may have found on the internet, or through parent support groups.

But what if there still is not ONE absolutely clear and convincing answer?

What if things are still muddy enough that there is room for debate? Lets say a child is diagnosed with a rare disorder, that may have many different manifestations. What if the symptoms the child is having are not to be found in any textbook or journal article describing that specific disorder?

That is where judgment comes in.

Physicians should be looking at everything they know, everything they can discover about the disorder, and looking at the specific needs of the child, and then work in concert with the family to determine the best path. Will that be the ONE RIGHT PATH?

NOT NECESSARILY

But the path needs to make sense in the current time, with knowledge that is available. That path may change with time, as more is learned, or the symptoms evolve and change.

So, what if I have two (or more) sets of experts who disagree with each other on how to proceed? For me, the answer is relatively simple: I defer to the choice an informed family has made as to the preferred path. Remember, the family knows their child better than any of us ever can. They know the subtleties of that child's behavior, and how it changes with perturbations of the illness. They may be able to detect signs of illness before there are any OBJECTIVE findings.

We should listen. We must listen.

Do I always know what is right?

NO

But I always strive to know what I don't know, and to listen to all sides of such an issue. My role might be to sit with the parent and ask them questions about what they understand about different options, to help clarify their opinion. What if I disagree with a plan in place? I have to do what I feel is in the best interest of the child; but defining BEST INTEREST is often problematic. It needs to take into consideration more than strict medical issues. It needs to include family values (not physician values), quality of life, social considerations, and more. This is one example of the ART of medicine.

If you are a health care provider, I would love to hear your thoughts on this matter. If you are a medical educator, or learner, let me know how you think this aspect of medicine is best taught.  If you have read this post, and you have an opinion, PLEASE share it.

 Eric Glazer  Vice President  Physician Engagement and Social Media  Best Doctors, Inc.

Unnecessary or inappropriately-used medical tests don't only waste time, money and resources: they can harm patients by delaying or denying a correct diagnosis. Here are four action steps doctors can take to avoid inappropriate testing:

4 Ways for Doctors to Avoid Inappropriate Testing from Best Doctors