Fantastic video! Thank you so much. One thing I was not able to understand: how would you approach someone with current ongoing vertigo but no nystagmus? Would you proceed w/ HINTs exam? Thank you

@PeterJohns

Жыл бұрын

Excellent question. No, I would not do the HINTS exam on them, as the HINTS exam has not been tested in this population. However, you should be worried about them if they have persistent dizziness AND a new difficulty walking. Machner pubmed.ncbi.nlm.nih.gov/32462345/ defined the Acute Imbalance Syndrome as patients who were sill dizzy in the ED, had an objective new problem with stance or gait, and NO nystagmus at rest. It should be noted that these patients had "an acute and unclear type of dizziness who required admission to a neurological ward for further diagnostics and treatment." A third of these patients had an acute brain lesion on their delayed MRI. If they had a ABCD2 score of 4 or higher, it was 50%. So you should be very worried about these patients, because all patients with vestibular neuritis will have spontaneous or gaze induced nystagmus at rest in the first several days. So if your patient presents in the first several days of their illness with constant dizziness and gait disturbance doesn’t have nystagmus, it ain’t vestibular neuritis, and that just leaves a whole bunch of strokes. It’s never been studied as far as I know, but I believe that it’s true that patients who complain of constant dizziness, screen negative for central features, have no nystagmus and no objective difficulty with gait are very low risk patients.

Thanks so much. You make teaching my fellow and the residents (and attendings) so much easier. Charlie

Your videos might be the best videos I've ever seen! I would love if you would cover other common emerge/ family presentations . I'd love to learn your approach

Really appreciate the thorough content. Thank you for making this wonderful video. It really helps a lot!

This doc is amazing.

Excellent 2 videos Peter well done

I wish that you publish more videos. All of them are very educational. Thank you Dr. Peter

Truly outstanding!

Better than any vertigo lecture I had in medical school. Thanks!! (I guess my teacher was bad)

@PeterJohns

8 жыл бұрын

+diana rodriguez espinosa Thank you!

Thank u so much u r a gem!!!!!

Thank you so much for explaining the complex topic of vertigo and making it so palatable.

My God!! So helpful, thank you!!!

You are telling me! Thank you!

thank you Dr, very good demonstration of approach to dizziness

Again, well done!

Thanks a lot again for sharing your expertise. I’m using it on Urgencies and the patients are grateful, for the cure or for diagnosing canalolithiasis that other colleagues didn’t find. Congrats and thanks for this, one year after learning in your videos.

@PeterJohns

5 жыл бұрын

Nice to hear you find it useful.

I just spent the last 3 hours wallowing through articles and podcasts. I wish I had found this video sooner. It would have saved me so much time! Learning the HINTS exam seems like the crux of learning how to assess vertigo

@PeterJohns

8 жыл бұрын

Thanks! Have you seen this one? Brand new! Let me know what you think. kzread.info/dash/bejne/Y6VhuLaEgNrLpc4.html

Great job doc

was really good, thank you. i will suggest these videos to my colleagues.

Superb, again! Thanks a lot!

GP,s throughout the country would really benefit from watching these very well presented videos. So much time and money could be saved by avoiding often unnecessary scans and tests.

@PeterJohns

5 жыл бұрын

I couldn't agree more. Trying to teach vertigo with written words and diagrams only is almost impossible in my opinion. Medical journal articles about vertigo which are published without easily accessible videos of the abnormal eye findings or techniques described are doing a disservice to the non-vertigo expert and the many patients that are seen by non-vertigo experts.

Excellent video ,i work as after hour gp and really found this very helpful ,its so simplified and easy to apply ,thanks alot Dr.

Videos are great for teaching residents and medical students.

Thank you so much.Very good

Thank you so much

very, very helpful!

thanks a lot !

Well Done!

Perfect!

Really good lecture on vertigo - concise

Someone asked: "Won't the nystagmus in vestibular neuritis be towards the affected ear? Since it's an irritative condition and nystagmus is always towards the active or hyperactive side." For some reason I can't reply directly to the person who asked the question. But the answer is explained in the video below. In vestibular neuritis, the nerve is not "irritative" , it loses function. and the difference between the two ears makes the brain think the head is turning towards the good ear, even when it's not. So the VOR makes eye deviate towards the affected ear, and the corrective fast component is towards the good ear. kzread.info/dash/bejne/dJ6sqKehhN26lqg.html

Hi Peter im an advance trainee in Australia Ur videos are brilliant. Can u do one on syncope, which is another Pain in ...

الف رحمة على روح والديك

thanks alot sir...its very easy

First time I understand Vertigo

Dr Johns, Can you talk about your approach to the patients with vague complaints of dizziness / vertigo, but no nystagmus seen on exam spontaneously nor reproducibly (during dix hallpike or other maneuvers)? In these patients, as you say, we can't use HINTS exam to reassure us that its not a stroke. Is it safe to approach these patients and document something like "patient has nonspecific dizziness symptoms, but with no objective signs of nystagmus or ataxia, no associated neurological sx, and a normal neurological exam, I have a low suspicion for central or peripheral vertigo syndromes. (of course I'd also address cardiovascular causes for lightheadedness/dizziness). Is there anything else you'd be looking for before writing these away on your ddx? Is it possible to have a central stroke without any objective findings including nystagmus? As you know, so many patients complain of dizziness, and it would be great to know when to take it seriously and when we can just consider it a nonspecific part of whatever else they have going on with them. Thanks!

@PeterJohns

6 жыл бұрын

And excellent question, and one that has not been addressed fully by clinical studies. I would add in list of pertinent negatives "no sustained significant headache or neck pain" and "no D's" which would include diplopia, dysarthria, dysphagia, dysphonia or dysmetria. Also, no focal weakness or paresthesias. And finally, that the patient was able to walk unaided. If all of this was negative, the chance that they are suffering from an acute event such as ischemic stroke is very low. Follow up is important for persistent symptoms. Vanni's study which recently as published is worth having a look at. "Differential diagnosis of vertigo in the emergency department: A prospective validation study of the STANDING algorithm." If the symptoms are recurrent (more than 5 episode) and last anywhere from 5 minutes to 3 days the most common diagnosis (and very commonly missed diagnosis) is vestibular migraine. I hope to make a video about this diagnosis soon. Thanks for your question, hope this helps.

If someone has intermittent vertigo (even lasting several hours but with periods vertigo-free), would it be unlikely for them to be having a posterior stroke?

@PeterJohns

3 жыл бұрын

The most common cause of intermittent vertigo which is not BPPV, is vestibular migraine. kzread.info/dash/bejne/ioR927qippO7e8o.html TIA is much rarer. kzread.info/dash/bejne/a5Ojkqdqed3Zc7A.html

What about if i got a patient in the ER with acute dizziness infront of me What should I do?

@PeterJohns

4 жыл бұрын

Watch a more recent video, "The Big 3 of Vertigo" kzread.info/dash/bejne/f6uW06yvfafVnrg.html . Let me know if you have questions after that one.

Sir as we have inferior vestibular irretaion vn will have positive Dix halpics

@PeterJohns

2 жыл бұрын

Inferior VN is fairly rare. I'm not sure exactly what would be seen in a DHT in this situation, but it wouldn't be a classic positive DHT with latency, and lasting 15 or so seconds with vertical upward, rotatory nystagmus, and only on one side.

Doc can we rule out a stroke if there is no nystagmus?

@PeterJohns

Жыл бұрын

Patients who are still dizzy and have a new problem with gait or balance and have no nystagmus have a high risk of stroke.

Could do video on menire?

@PeterJohns

5 жыл бұрын

I rarely see Meniere's in the emergency department. I don't feel comfortable making videos about things I don't see clinically.

Anki brought me here

What about ototoxicity?

@PeterJohns

2 жыл бұрын

Not the purpose of this video to discuss it, as it is fairly rare compared to BPPV, VN and stroke.

Could directional changing nystagmus result from a 30 year alcoholic going “cold turkey” .....the Dr. at the hospital diagnosed the patient with BPPV .......although the patient reported that he was spinning 24/7 for 2 weeks, vomiting, unable to walk straight or drive, didn’t really feel good even when lying down. Since it was a month without drinking the Dr. felt that it couldn’t be related to continued waves of Detox from alcohol ......30 year addiction with daily intake of a fifth of Captain Morgen plus “some beers”. Hmmmmmmm......

@PeterJohns

5 жыл бұрын

Sorry, can't diagnose over the internet.