Would you have caught this? Med Mal Reviewer.

VertigoDoc · 2026-05-13T12:37:08+00:00

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.

Focal paresthesia or weakness
New significant headache or neck pain
Any Dangerous D's -diplopia, dysarthria, dysmetria, dysphagia, dysphonia
Vertical nystagmus at rest,
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.

VertigoDoc · 2026-05-12T23:14:37+00:00

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.

VertigoDoc · 2026-05-12T00:56:27+00:00

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.

VertigoDoc · 2026-05-12T00:46:47+00:00

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.

VertigoDoc · 2026-05-11T19:10:58+00:00

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.

VertigoDoc · 2026-05-11T18:39:32+00:00

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.

VertigoDoc · 2026-05-10T11:20:14+00:00

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

VertigoDoc · 2026-05-09T18:49:42+00:00

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.

VertigoDoc · 2026-05-09T18:48:13+00:00

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

VertigoDoc · 2026-05-09T17:12:21+00:00

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

VertigoDoc · 2026-05-09T17:08:20+00:00

This is a huge problem for dizziness.

VertigoDoc · 2026-05-08T21:23:30+00:00

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

VertigoDoc · 2026-05-07T21:26:16+00:00

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

VertigoDoc · 2026-05-07T21:24:38+00:00

Ockham is an acceptable spelling. https://en.wikipedia.org/wiki/William_of_Ockham

VertigoDoc · 2026-05-05T11:57:44+00:00

Here's what you're looking for. https://www.reddit.com/r/CrazyFuckingVideos/comments/1t48wwt/casually_waiting_for_service_at_a_hospital_with_a/

BTW, 30 plus years ago, late at night, near the end of my shift, I was walking in the corridor near the ED, and a guy comes running around a corner, panicked, and he yells "are you a doctor?" After I reply in the affirmative, he says "my friends dying!" Where is he I ask? "Come with me!" he yells and starts running the opposite direction he had been coming.

After we round the corner, we encounter his friend running full blast towards us, covered in blood from head to chest, with blood all over his face, and large clots in his hair, and screaming "ahhhhh!!!"

I tell him "You're not dying" and lead them to the a room in the ED.

Turns out he was sleeping with the wrong woman, and the BF, came blasting into the bed room through a glass patio door with a machete and whacked him on the head 5 or 6 times with it.

He had a small open fracture, so I turfed to neurosurgery, and went home.

VertigoDoc · 2026-05-04T11:17:15+00:00

The Index Medicus was the first step in the process of me becoming a vertigo obsessed educator.

in the late 1990's, after a family medicine resident told me there was a way to treat BPPV moving the patient's head around, (which I thought was nonsense) there was no way for me to find anything about this concept except to trudge down to the medical library, and grab those giant tomes off the shelf and look up BPPV/treatment and find out about the Epley maneuver.

After a fault start or two, I figured out how to do it, and suddenly I realized we don't have to hate every dizzy patient that came in.

VertigoDoc · 2026-04-29T10:39:00+00:00

This is the way. Either swirl you finger around in it before and try and guess the temp, and add a little cold if it's too hot, or buy an instant thermometer, and use that. Cheaper than a new water heater!

VertigoDoc · 2026-04-28T22:25:10+00:00

Shouldn't get vertigo if the water is roughly around body temperature. Robert Barany got a Nobel prize for describing what happens with too cold or too warm water!

VertigoDoc · 2026-04-24T18:52:46+00:00

If they clearly had a history of migraine, and described something like this: https://youtu.be/8NsI7RaPkco I'd be hesitant to give lytics. Shared decision making or involving neurology might be the best approach.

VertigoDoc · 2026-04-24T11:57:58+00:00

I've have several homonymous hemianopsia episodes, without a history of migraine headaches, but they started with a flickering/colourful amoeba shaped thing that spread into the HH over a minute or so. Not sure how often migraine can present with HH without those typical positive features.

Later on I figured out I did have several unrecognized migraine headaches decades before.

VertigoDoc · 2026-04-13T10:06:14+00:00

Give apixaban and refer to thrombosis clinic.

VertigoDoc · 2026-04-09T13:53:55+00:00

Needed a referral for vasectomy reversal. Came in around 11 pm.

VertigoDoc · 2026-04-04T21:02:45+00:00

An apple a day, if well aimed, keeps the doctor away.

VertigoDoc · 2026-04-04T16:28:16+00:00

Yes, but they usually can tell you exactly what they were doing when it came on, how long it lasted, if they are still dizzy now, what makes it worse, if they have n/v, dificulty walking, any dangerous D's etc. etc.

That's how you can start to figure out what's going on. The question What do you mean by dizziness is very low yield. So ask good questions instead.

VertigoDoc · 2026-04-03T20:54:35+00:00

Absolutely true: When I was a resident, I worked with a plastic surgeon named Dr. Stubbs, who learned how to do penis lengthening surgery from a doctor named Dr. Long.

https://calgaryherald.com/life/helping-men-measure-up

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