The Timing-and-Triggers Approach to the Urgent Care Patient With Acute Dizziness (Stroke CME)

Publication Date: February 2024 (Volume 3, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 02/01/2027.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 1 Stroke CME credit, subject to your state and institutional requirements.

Adapted By

Joseph Toscano, MD, FCUCM

Urgent Care Physician, John Muir Urgent Care, Walnut Creek, CA; Emergency Physician, San Ramon Regional Medical Center, San Ramon, CA

Peer Reviewers

Sean M. McNeeley, MD, FCUCM

Medical Director, University Hospital Occupational Medicine and Employee Health;

Clinical Instructor, Case Western Reserve University School of Medicine, Cleveland, OH; Past President, Urgent Care Association

Coding Author

Bradley Laymon, PA-C, CPC, CEMC

Certified Physician Assistant, Winston-Salem, NC

Acknowledgment

This content was adapted from: Edlow JA. The timing-and-triggers approach to the patient with acute dizziness. Emerg Med Pract. 2019;21(12):1-24. Used with permission of EB Medicine.

Abstract

Acute dizziness is a common presentation in the urgent care setting. Due to newer research, the diagnostic approach to dizziness has changed, now focusing on its timing and triggers of instead of the patient’s symptom quality (vertigo vs lightheadedness). Each timing-and-triggers category has its own differential diagnosis and diagnostic approach, which will aid clinicians in distinguishing benign causes of dizziness from life-threatening causes. Brain imaging, even with magnetic resonance imaging, has important limitations in ruling out stroke presenting with dizziness, elevating accurate clinical diagnosis to an even greater level of importance. Benign paroxysmal positional vertigo can be treated with repositioning maneuvers at the bedside, offering cost-effective management options.

Case Presentations

CASE 1

A previously healthy 44-year-old man presents to urgent care with dizziness that has been present for 6 hours...

He describes unsteadiness and “feeling like I am drunk,” and has vomited 3 times.
He denies headache or neck pain, weakness, or numbness. His vital signs are normal.
There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze.
Your colleague who examined him before you arrived reports that the patient’s head impulse test is normal.
Hearing all of this, you consider treating with meclizine and having him follow-up with his PCP in 2 days, but you wonder if there is something else that needs to be considered...

CASE 2

A 70-year-old woman arrives at the clinic with a complaint of “lightheadedness” that has been going on for 5 days...

She says the feeling goes away at times, and gets worse when she gets out of bed. The dizziness has woken her from sleep several times.
She has hypertension and high cholesterol. Her vital signs are normal.
Sitting up on the exam table, she is asymptomatic but feels apprehensive about moving her head. There is no nystagmus in primary gaze.
You wonder if you should send her to the ED for a head CT or if there is a better diagnostic test...

CASE 3

A 58-year-old diabetic man presents with a chief complaint of syncope...

On further questioning, he is reporting vertigo that is so severe it made him ease himself to the ground. There was no trauma, and it began abruptly 3 hours prior.
Fingerstick glucose is 110 mg/dL.
There is nystagmus on primary gaze that beats to the right, and when he looks to the right the amplitude of the nystagmus increases.
He is very nauseated and has vomited 3 times. A head impulse test is positive. Skew deviation is absent and he is mildly unsteady but can walk unassisted.
You wonder if this could be stroke and whether emergent transfer to the ED is needed...

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.