Annals of Emergency Medicine
Volume 50, Issue 2 , Pages 204-205, August 2007

Charted Records of Dizzy Patients Suggest Emergency Physicians Emphasize Symptom Quality in Diagnostic Assessment

Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD

Article Outline

 

To the Editor:

Dizziness is the chief complaint in approximately 4% of emergency department (ED) visits.1 The traditional approach to dizziness relies heavily on symptom quality to inform diagnosis.2 Recent research indicates that symptom quality may not be a reliable enough clinical parameter to be used for diagnostic purposes.3 Alternative approaches to diagnosis focusing on dizziness timing and triggers, along with associated symptoms (eg, pain), have been proposed.4 The purpose of this study was to test the hypothesis that emergency physicians emphasize symptom quality over other symptom dimensions when diagnosing dizzy patients, as evidenced by their charting habits.

We conducted a retrospective chart review of patients with a triage complaint of dizziness at a single, urban ED. From our triage database, we identified 1144 adult patients (ages 18-98) with complaints compatible with dizziness over a 1-year period (7/99-6/00). There were 632 patients logged as “dizzy,” “dizziness,” or “vertigo;” 482 patients logged as “lightheaded,” “presyncope,” “faint,” or “syncope;” and 30 patients logged as “ataxia,” “unsteady gait,” or “off balance.” We reviewed 92 randomly selected charts to assess attributes of dizziness charted. A single, unmasked reviewer (neuro-otologist) abstracted 5 elements of history recorded about each patient: (i) date/time of first symptoms, (ii) quality of dizziness, (iii) associated pain, (iv) triggers for dizziness, and (v) episode duration.

In more than half of charts reviewed, none of the prospectively defined attributes were documented. In some cases, this was because the encounter was truncated (eg, left without treatment), in others because dizziness was not the focus of diagnostic inquiry (eg, some cases of syncope without dizziness/presyncope), and in others because of generally limited documentation. Among 43% (40/92) of charts in which at least 1 of 5 attributes was documented, 90% included the date or time of first symptoms, 70% included the quality of the dizziness, 50% included the presence or absence of pain, 30% included the presence or absence of triggers, and 13% included the episode duration. In total, among charts with at least 1 attribute documented, 30% contained no mention of pain, triggers, or episode duration.

Although it is impossible to discern all aspects of an emergency physician’s diagnostic reasoning from a chart review, some inferences about the process may be drawn from the information documented (and not documented) in charts. From these data, it appears that the quality of dizziness is given more diagnostic weight than other attributes of the complaint-specific history, including episode duration, triggers, and co-morbid pain.

However, these other dizziness attributes may have significant diagnostic value. For instance, it is believed that brief, recurrent episodes of dizziness imply a starkly different differential diagnosis (eg, benign paroxysmal positioning vertigo, transient ischemic attack) than a single, acute, prolonged bout (eg, vestibular neuritis, cerebellar stroke).5 Dizziness triggers are thought to differentiate between key disorders, once a limited differential diagnosis based on episode duration is defined (eg, benign paroxysmal positioning vertigo versus transient ischemic attack).6 In a dizzy patient, head or neck pain may be a warning sign of vertebral artery dissection, preceding the onset of stroke by up to 2 weeks.7 Given the substantial risks associated with missed cerebrovascular causes for dizziness,8 greater attention to these “forgotten” symptom parameters may be warranted.

Limitations include retrospective design, single chart abstractor, and lack of definitive diagnoses for patients. These are important limitations. Nevertheless, these preliminary data are not surprising, given the dominant paradigm for evaluation of dizzy patients is based on the premise that symptom quality (vertigo, presyncope, disequilibrium, non-specific dizziness) reflects the underlying disease mechanism or etiology (vestibular, cardiovascular, neurologic, psychiatric/metabolic).2

This “quality-of-symptoms” approach derives from a 35-year-old study, focused on assessment of chronically dizzy patients, and conducted in a subspecialty outpatient clinic prior to the advent of modern neuroimaging.9 As originally described, it relies on an exhaustive search for possible etiologies of dizziness after initial classification based on symptom quality. Such an approach may not be well suited to the ED environment, where evaluations are time-pressured and oriented towards triage of high-risk dizzy patients (eg, stroke, arrhythmia) rather than definitive, final diagnosis.4 If abridged after the initial qualitative classification of dizziness, a faulty decision regarding diagnostic testing or disposition might well be made. Furthermore, recent ED-based research suggests that dizzy patients cannot clearly, consistently, and reliably report symptom quality, while they can do so for dizziness timing and triggers,3 raising further doubts about whether the traditional quality-of-symptoms approach is applicable in an acute care setting such as the ED. Future studies should assess any possible association between ED provider focus on symptom quality and misdiagnosis of ED dizzy patients.

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References 

  1. Cappello M, di Blasi U, di Piazza L, et al. Dizziness and vertigo in a department of emergency medicine. Eur J Emerg Med. 1995;2:201–211
  2. Drachman DA. A 69-year-old man with chronic dizziness. JAMA. 1998;280:2111–2118
  3. Newman-Toker DE, Guardabascio LM, Zee DS, et al. Taking the history from a dizzy patient: why “What do you mean by dizzy?” should not be the first question you ask. [abstract] Acad Emerg Med. 2006;13(Supplement 1):S79
  4. Newman-Toker DE, Zee DS. Building a new model for diagnosis of dizzy patients in the emergency department. [abstract] J Vestib Res. 2002;11:281
  5. Baloh RW. Vertigo. Lancet. 1998;352:1841–1846
  6. Newman-Toker DE, Camargo CA. ‘Cardiogenic vertigo’--true vertigo as the presenting manifestation of primary cardiac disease. Nat Clin Pract Neurol. 2006;2:167–172
  7. Saeed AB, Shuaib A, Al-Sulaiti G, et al. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci. 2000;27:292–296
  8. Savitz SI, Caplan LR, Edlow JA. Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med. 2007;14:63–68
  9. Drachman DA, Hart CW. An approach to the dizzy patient. Neurology. 1972;22:323–334

 Funding and support: The author reports the preparation of this manuscript was supported by grants from the Foundation for Education and Research in Neurologic Emergencies, and the National Institutes of Health (National Center for Research Resources (NCRR) K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients”).

PII: S0196-0644(07)00553-7

doi:10.1016/j.annemergmed.2007.03.037

Annals of Emergency Medicine
Volume 50, Issue 2 , Pages 204-205, August 2007

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