We’ll continue on with assessing the folks that show up with a sudden case of the dizzies. Today we’ll look at the physical examination.
The physical examination is important as well in this population and requires some skill to perform. Many clinicians of all disciplines shy away from learning these skills as they are a little nuanced. However, if you’re going to accurately diagnosis this population, you have to get in there and get your scrubs dirty. Like I said before, there are very few blood tests or imaging you can do in this realm to rule things in or out, which makes the physical exam 100% necessary and needs to be done well.
First, we need to check eye ball movement to determine if the vestibular-ocular reflex (VOR) is intact or not. So you’ll have the person look left and right and look for nystagmus— a slight beating motion super imposed on left or right motion. Also note it’s intensity in those motions. Is one direction more intense than the other? I always check up/down motion as well personally. Then you’ll want to check if this can be suppressed or made better with light. Which can be done by removing the environmental light using Frenzel goggles, an ophthalmoscope or just have the person close their eyes and watch their eyes move under their eyelids. Then you’ll also want to perform the head impulse test (HIT). This is one of the ones that scares people to do. “Am I going to rip their head right off their neck?” That was the worry I had learning this. Nope, that’s not necessary. Using a lot of force isn’t necessary either. You just need the speed to be quick to get an accurate result. I do check their vertebral arteries before I do this one though, just to be sure. Here’s a video with a positive HIT result on the patient’s left
You’ll also want to do a quick Dix-Hallpike Maneuver on both sides. This is another one that tends to scare people to do. This one also doesn’t need a lot of force and it doesn’t need be done all that quick either. Although I have seen demos of this that like a WWE wrestling move. I’ll sometimes have a tech stand by in case the patient gets really dizzy and scared the person has someone to grab onto– the tech– besides me while I watch the result. Techs are also good vomit bucket holders. Have to watch your shoes on this one! Here’s a video, although I wouldn’t bother doing it 3 times honestly:
Then we have the Romberg test. This one can also be scary as if you get a true positive test, the person WILL fall. Which is why I never do this test personally. Falls aren’t allowed on my watch when I can help it, because 1 fall=2 hours of paperwork. No thank you; I have better things to do.
Then you can observe the person walk in tandem or heel-toe. Does this make them fall over? Again, I don’t do tests that make people fall over. Perhaps I’ll feel more comfortable doing these tests once our overhead track system gets installed. Until then, no.
Then you’ll want to do a quick hearing screen, take a look into their ear with an otoscope, complete a general and basic neuro screen.
That sums up the physical examination. Next up, what conditions you’ll be ruling in/out with these tests aka the differential diagnosis!
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