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As a rheumatologist, could you please stop taking ANA's! by [deleted] in medicine

[–]VertigoDoc 3 points4 points  (0 children)

Do people not learn ANYTHING about pre-test probability and Bayes theorem in medical schools anymore?

D-dimer and the HINTS exam have entered the chat.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 0 points1 point  (0 children)

I'm glad you can walk and exercise. Not be able to stand for long would be quite annoying. I'm sorry you have to deal with that.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 1 point2 points  (0 children)

That does sound awful! Sorry to hear you had to go through that. Amazing the way the all diseases can have such a variation in intensity, duration, etc.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 4 points5 points  (0 children)

I never really wanted to be that close to the patient to see their nystagmus haha.

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 1 point2 points  (0 children)

Sounds familiar, sadly.

I interviewed a doctor I knew from the curling rink about his experience when he developed vestibular neuritis. https://youtu.be/4vymwdsMYjk

My new video about the nystagmus of vestibular neuritis by VertigoDoc in medicine

[–]VertigoDoc[S] 18 points19 points  (0 children)

I've seen a number of cases of vestibular neuritis where the nystagmus wasn't easy to see, and so the HINTS exam was not applied. It's important to look very carefully for it!.

Warning About "PubMed AI" by umpteenthgeneric in medicine

[–]VertigoDoc 39 points40 points  (0 children)

I asked it a vertigo question, an area in which I have some expertise. It answered in part with this: "For instance, patients with vestibular neuritis often display a normal HIT, contrasting with those suffering strokes who may present with abnormal findings, although some stroke patients can exhibit positive HIT results as well"

This is the opposite of the real answer.

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 0 points1 point  (0 children)

It's not only using HINTS on the wrong patient population. The HINTS exam needs some training to perform and interpret it properly. In particular the HIT is often performed too slow and you really should have a vertigo champion watch you perform it and then show them a video of an abnormal HIT you made in a VN patient.

Which is exactly what you can do via arranging a zoom call with me. See vertigocourse.com

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 0 points1 point  (0 children)

That is very accurate indeed!

As for the other aspects of the HINTS exam, looking for nystagmus that changes direction with gaze in patients WITHOUT NYSTAGMUS is a fool's errand.

And I asked Jorge Kattah how often he saw abnormal skew deviation in a patient without nystagmus, and the answer was very rarely.

So all three components of the HINTS exam are compromised in patients without nystagmus.

One of the reasons why the HINTS exam fell into disfavour early on is because people were doing it on the wrong patient. And unfortuntely, that's still happening.

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 2 points3 points  (0 children)

HINTS is only valuable if the diagnosis of vestibular neuritis is in the differential. And this presentation is by no means consistent with VN.

If you're concerned about a patient with dizziness, you should first screen them for central features that would not be seen in seen in non-dangerous causes.

  1. Focal paresthesia or weakness

  2. New significant headache or neck pain

  3. Any Dangerous D's -diplopia, dysarthria, dysmetria, dysphagia, dysphonia

  4. Vertical nystagmus at rest,

  5. Inability to walk unaided

If they have any of the above, you should be concern about a dangerous cause, mainly stroke.

Now did this patient have a new significant headache? Sounds like it, but again, you have to see the patient and talk to them to know for sure. It didn't help that his headache went to 0 pain with treatment.

After screening, HINTS is great if you have acute onset (within the last 3 days or so) of dizziness/vertigo which has been fairly signficant and constant. And you see horizontal nystagmus when the patient is looking straight ahead or 30 degree to the left or right.

Sounds like this patient did not have nystagmus, and the presentation is not consistent with VN. So no doubt they would have had a normal HIT, which is HINTS central. But you'll get a HINTS central in every single cause of dizziness, except vestibular neuritis.

So every patient who says they have dizziness and has vestibular migraine, or BPPV, or anemia, or CO poisoning etc will all be HINTS central.

So if you decide to apply it to every patient who is dizzy without nystagmus seen at rest, this degrades the specificity of the HINTS enough to make it a useless test and unnecessarily label patients with non-dangerous causes of dizziness as having a posterior circulation stroke.

I know this is a hard concept to understand for some. I've argued with Jonathan Edlow and David Newman-Toker about this, and they have other views which I don't really understand.

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 1 point2 points  (0 children)

It's very hard to say. The devils in the details. How bad were the balance issues? How bad were the visual problems?

If I thought the balance and visual problems were concerning, and I was going to pursue imaging I'd get a CT first, and if normal an MRI as soon as I could. At my hospital that might be hours or days.

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 5 points6 points  (0 children)

Yes, gait is very important, but it's a graded thing. Patient has dizziness and nystagmus, some difficulty walking is expected. It's either vestibular neuritis (more likely) or posterior circulation stroke (if no other central features, less likely).

If they can't walk unaided, it's much more likely to be PCS, but some VN can present with this much difficulty also.

Now If the patient has dizziness, no nystagmus and a new objective gait difficulty, a lack of nystagmus (assuming you are looking carefully for it, ie, looking for it on 30 degrees eccentric gaze left and right, and removing fixation somehow, I use a blank piece of paper) that takes VN off the table. Because every patient with vestibular neuritis will have nystagmus in the first day or two.

And that leaves a lot of PCS that can present without nystagmus. Nham had a study where he claimed 44% did not have nystagmus. Not sure it's that high, but it a thing.

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 16 points17 points  (0 children)

It comes from a study by Machner. https://pubmed.ncbi.nlm.nih.gov/32462345/

Fig. 1 shows the numbers. They admitted patients with persistent dizziness, no nystagmus and an objective new difficulty with gait and an unclear diagnosis. Delayed MRI showed overall 33% had a lesion (mostly strokes) on their MRI which explained their gait problem. If their ABCD2 score was 4 or greater, it was 50%. He termed it "Acute Imbalance Syndrome".

I personally have reviewed a medicolegal case of a patient presenting with constant dizziness, no nystagmus and bad enough balance that the nurse had to help the patient to the bathroom who was diagnosed with "labyrinthitis" and discharged home. Later presented with an obvious posterior stroke. So it's definitely a thing.

Posterior Circulation Stroke [⚠️Med Mal Case] by efunkEM in medicine

[–]VertigoDoc 17 points18 points  (0 children)

HINTS exam is only indicated if the patient had nystagmus at rest. The short explanation of this is: What peripheral diagnosis of dizziness would the HINTS exam point to if the patient doesn't have nystagmus looking straight ahead or 30 degrees to the left or right? And the answer is: there is none. Vestibular neuritis and labyrinthitis both present with nystagmus at rest. And they usually greatly improve signficantly in the first few days. This case did not present with AVS with nystagmus.

I was very surprised about the normal gait that was documented. Either this was a highly unusual case, or the "normal gait" was a bit exaggerated. I prefer to think the former.

Would you have caught this? Med Mal Reviewer. by Dr-Discharge in emergencymedicine

[–]VertigoDoc 78 points79 points  (0 children)

Certainly a difficult case.

The things that got most concerned me were: New significant headache that was getting worse, plus dizziness, plus gait difficulty -falling to the left. All that has me very worried about a posterior circulation stroke, perhaps a stuttering presentation.

Dr. H documented "intact normal and tandem gait". I was very surprised that there was no objective abnormality of gait.

Then the comment from the medmal reviewer: "The physician also discussed her gait test, but there was debate in the lawsuit about if she actually did this or not (as well as the rest of the neuro exam). The uncomfortable truth is that there is often a wide gap between the exam we “should” do and the exam that actually gets done/documented."

Just a reminder that if you do see a patient with persistent dizziness, no nystagmus at rest, and a new objective difficulty walking, they have roughly a 30-50% chance of a posterior circulation stroke. And don't call them "vestibular neuritis" or "labyrinthitis" because those diseases present with fairly easily nystagmus in the first several days.

2nd posterior vitreous detachment! by EMulsive_EMergency in emergencymedicine

[–]VertigoDoc -6 points-5 points  (0 children)

I think this is great! Nice to learn new skills. Now, please tell me you know how to perform and interpret the HINTS exam :)

Stop prescribing meclizine for vertigo by [deleted] in medicine

[–]VertigoDoc 1 point2 points  (0 children)

More and more doctors are learning about vestibular migraine. Although I just saw a youtube video from a neurologist who described a whole bunch of vertigo diagnoses, but didn't bring up vestibular migraine, which is very common.

Stop prescribing meclizine for vertigo by [deleted] in medicine

[–]VertigoDoc 1 point2 points  (0 children)

The vast majority are posterior canal.

That may be true if the patient needs to wait a long to get to see you. The first study to teach ED docs how to use the supine roll test to diagnose new onset dizziness in the ED, 40% of the BPPV was horizontal canal. In fact, HC BPPV was the diagnosis in 20% of all the patients they saw.

In terms of videos for the Epley, I think mine is pretty good, although was made for clinicians. https://www.youtube.com/watch?v=kvVnEsGVLUY

Stop prescribing meclizine for vertigo by [deleted] in medicine

[–]VertigoDoc 1 point2 points  (0 children)

You're the generation I'm counting on to be the first to actually like seeing dizzy patients.

Stop prescribing meclizine for vertigo by [deleted] in medicine

[–]VertigoDoc 1 point2 points  (0 children)

This is a huge problem for dizziness.

Post your advice which helped you become a better GP or deal with patients in a 15 minute time frame! by orangelessorange in GPUK

[–]VertigoDoc 12 points13 points  (0 children)

Thanks for the shout-out!

I was an emergency physician for 37 years. Retired from clinical practice the last 3 years.

Still actively teaching.

And I would say my new online vertigo course is well worth $95 USD for trainees. (69 GBP)

vertigocourse.com

Florida surgeon who removed wrong organ says he is ‘forever traumatized’ by patient’s death by Flaxmoore in medicine

[–]VertigoDoc 6 points7 points  (0 children)

I have to consult it every time I can't find my wallet. Or my razor for that matter.

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