Matthew Siket, MD, MS, FACEP, used his ACEP19 session on dizziness to demystify the symptom’s diagnosis and treatment. But first, he asked a room full of emergency physicians to raise their hands if they hated those symptoms.

Martin Springer, MD, FACEP, raised his hand.

So did nearly every other doc in the room.

“I think we all do,” said Dr. Springer, who practices emergency medicine in the U.S. and Beijing. “And I know that there are these new exams people are doing. I’ve tried doing it and obviously now, according to this lecture, it’s clear to me that I chose the wrong patients to do it on.”

Welcome to “Why ‘What Do You Mean Dizzy?’ Should Not Be the First Question You Ask of a Dizzy Patient,” led by Dr. Siket, of Robert Larner College of Medicine at the University of Vermont.

Perhaps Dr. Siket’s best advice for frustrated emergency physicians was the course title. He told doctors to stop kicking off exams by asking the age-old question of whether the presenting dizziness felt like lightheadedness or vertigo.

“Does that make any sense?” Dr. Siket asked. Telling a patient, “’Come on, lady. You’ve got to commit. Is this lightheadedness or vertigo? Question 1, I’m not proceeding until you give me that answer.’ … Don’t box in your patients. Don’t make them commit with that first question that’s just setting yourself up for diagnosis error.”

Dr. Siket noted that while dizziness is most often benign, it can have deadly underlying causes that are often missed.

“It’s awfully difficult to be diagnostically subtle and really hone in on these patients which present with mild or subtle deficits, if any at all, when our workplace environment is chaotic,” Dr. Siket said.

Dr. Siket’s clinical pearls focused on using a systematic approach. He urged the use of the ATTEST mnemonic (Associated symptoms, Timing, Triggers, Exam, Signs, Testing) to standardize that approach. He suggested physicians categorize vestibular syndromes by type to guide their workups. He added that both the presence and the type of nystagmus can help with differentiating between central and peripheral causes.

While physician confidence with the HINTS exam (Head Impulse test, Nystagmus, and Test of Skew) is relatively low, Dr. Siket said the tool is useful for some patients. He added that provocative testing should be used selectively to be sure that it is being applied to the right patient cohort.

Dr. Siket warned that physicians shouldn’t assume a cause of benign paroxysmal positional vertigo (BPPV) because a patient’s symptoms worsen with head movement. He also cautioned that incomplete neurologic exams can lead to misdiagnoses. Lastly, he noted that misunderstanding HINTs and the types of nystagmus can cause further diagnostic confusion.

Overall, Dr. Siket said using a systematic approach to help diagnose the cause of dizziness will make physicians more comfortable dealing with dizzy patients.

“I was able to change the way I approached dizziness. It makes me much more comfortable and confident,” Dr. Siket said, adding that he’s now “admittedly less guilty of just leaving that chart in the rack and playing chicken with the other providers to see if they jump at it first.”

 Richard Quinn is a freelance writer from New Jersey.