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Imprecision in Patient Reports of Dizziness Symptom Quality: A Cross-sectional Study Conducted in an Acute Care Setting

  • Author Footnotes
    1 Preparation of this study was supported by the National Institutes of Health, National Center for Research Resources K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients” (D.E.N.-T.) and grants from the Arnold-Chiari Foundation and the Albert Pennick Fund (D.S.Z.)
    David E. Newman-Toker
    Correspondence
    Individual reprints of this article are not available. Address correspondence to David E. Newman-Toker, MD, PhD, The Johns Hopkins Hospital, Pathology Bldg 2-210, 600 N Wolfe St, Baltimore, MD 21287
    Footnotes
    1 Preparation of this study was supported by the National Institutes of Health, National Center for Research Resources K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients” (D.E.N.-T.) and grants from the Arnold-Chiari Foundation and the Albert Pennick Fund (D.S.Z.)
    Affiliations
    Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD
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  • Lisa M. Cannon
    Affiliations
    School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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  • Matthew E. Stofferahn
    Affiliations
    School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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  • Richard E. Rothman
    Affiliations
    Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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  • Yu-Hsiang Hsieh
    Affiliations
    Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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  • Author Footnotes
    1 Preparation of this study was supported by the National Institutes of Health, National Center for Research Resources K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients” (D.E.N.-T.) and grants from the Arnold-Chiari Foundation and the Albert Pennick Fund (D.S.Z.)
    David S. Zee
    Footnotes
    1 Preparation of this study was supported by the National Institutes of Health, National Center for Research Resources K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients” (D.E.N.-T.) and grants from the Arnold-Chiari Foundation and the Albert Pennick Fund (D.S.Z.)
    Affiliations
    Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD
    Search for articles by this author
  • Author Footnotes
    1 Preparation of this study was supported by the National Institutes of Health, National Center for Research Resources K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients” (D.E.N.-T.) and grants from the Arnold-Chiari Foundation and the Albert Pennick Fund (D.S.Z.)

      OBJECTIVE

      To quantify precision in patient reports of different attributes of dizziness.

      PATIENTS AND METHODS

      In a cross-sectional study, we interviewed consecutive adult patients with dizziness at 2 urban academic emergency departments (EDs) from July 2, 2005, to August 26, 2005. We excluded patients who were too sick for an interview or who posed a risk to the interviewer. We included those who were “dizzy, light-headed, or off-balance” for 7 days or less or previously “bothered” by the same conditions. We assessed descriptions of dizziness quality elicited by 4 questions in different formats (open-ended, multiresponse, single-choice, and directed). Clarity was assessed qualitatively (vague, circular) and quantitatively (overlap of types of dizziness). Consistency was measured by frequency of mismatched responses across question formats. Reliability was determined by test-retest.

      RESULTS

      Of 1342 patients screened, 872 (65%) were dizzy, light-headed, or off-balance in the past 7 days (n=677) or previously bothered by dizziness (n=195). Among these 872 patients with dizziness, 44% considered dizziness “the main reason” or “part of the reason” for the ED visit. Open-ended descriptions were frequently vague or circular. A total of 62% selected more than 1 dizziness type on the multiresponse question. On the same question, 54% did not pick 1 or more types endorsed previously in open description. Of 218 patients not identifying vertigo, spinning, or motion on the first 3 questions, 70% confirmed “spinning or motion” on directed questioning. Asked to choose the single best descriptor, 52% picked a different response on retest approximately 6 minutes later. By comparison, reports of dizziness duration and triggers were clear, consistent, and reliable.

      CONCLUSION

      Descriptions of the quality of dizziness are unclear, inconsistent, and unreliable, casting doubt on the validity of the traditional approach to the patient with dizziness. Alternative approaches, emphasizing timing and triggers over type, should be investigated.
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      REFERENCES

        • Newman-Toker DE
        • Guardabascio LM
        • Zee DS
        • Rothman RE
        Taking the history from a dizzy patient: why “what do you mean by dizzy?” should not be the first question you ask [abstract 182].
        Acad Emerg Med. 2006; 13: S79
        • Kroenke K
        • Jackson JL
        Outcome in general medical patients presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up.
        Fam Pract. 1998; 15: 398-403
        • 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
        • Hoffman RM
        • Einstadter D
        • Kroenke K
        Evaluating dizziness.
        Am J Med. 1999; 107: 468-478
        • Stewart MG
        • Chen AY
        • Wyatt JR
        • et al.
        Cost-effectiveness of the diagnostic evaluation of vertigo.
        Laryngoscope. 1999; 109: 600-605
        • Wasay M
        • Dubey N
        • Bakshi R
        Dizziness and yield of emergency head CT scan: is it cost effective? [letter].
        Emerg Med J. 2005; 22: 312
        • Baloh RW
        Dizziness: neurological emergencies.
        Neurol Clin. 1998; 16: 305-321
        • Baloh RW
        Vertigo.
        Lancet. 1998; 352: 1841-1846
        • Hotson JR
        • Baloh RW
        Acute vestibular syndrome.
        N Engl J Med. 1998; 339: 680-685
        • Froehling DA
        • Silverstein MD
        • Mohr DN
        • Beatty CW
        The rational clinical examination: does this dizzy patient have a serious form of vertigo?.
        JAMA. 1994; 271: 385-388
        • Sloane PD
        • Coeytaux RR
        • Beck RS
        • Dallara J
        Dizziness: state of the science.
        Ann Intern Med. 2001; 134: 823-832
        • Drachman DA
        A 69-year-old man with chronic dizziness.
        JAMA. 1998; 280: 2111-2118
        • Stanton VA
        • Hsieh Y-H
        • Camargo Jr, CA
        • et al.
        Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians.
        Mayo Clin Proc. 2007; 82: 1319-1328
        • Herr RD
        • Zun L
        • Mathews JJ
        A directed approach to the dizzy patient.
        Ann Emerg Med. 1989; 18: 664-672
        • Weinstein BE
        • Devons CA
        The dizzy patient: stepwise workup of a common complaint.
        Geriatrics. 1995; 50 (49): 42-46
        • Derebery MJ
        The diagnosis and treatment of dizziness.
        Med Clin North Am. 1999; 83: 163-177
        • Lawson J
        • Fitzgerald J
        • Birchall J
        • Aldren CP
        • Kenny RA
        Diagnosis of geriatric patients with severe dizziness.
        J Am Geriatr Soc. 1999; 47: 12-17
        • Rosenberg ML
        • Gizzi M
        Neuro-otologic history.
        Otolaryngol Clin North Am. 2000; 33: 471-482
        • Hanley K
        • O'Dowd T
        Symptoms of vertigo in general practice: a prospective study of diagnosis.
        Br J Gen Pract. 2002; 52: 809-812
        • Delaney KA
        Bedside diagnosis of vertigo: value of the history and neurological examination.
        Acad Emerg Med. 2003; 10: 1388-1395
        • Kentala E
        • Rauch SD
        A practical assessment algorithm for diagnosis of dizziness.
        Otolaryngol Head Neck Surg. 2003; 128: 54-59
        • Clark MR
        • Sullivan MD
        • Fischl M
        • et al.
        Symptoms as a clue to otologic and psychiatric diagnosis in patients with dizziness.
        J Psychosom Res. 1994; 38: 461-470
        • Furman JM
        • Jacob RG
        A clinical taxonomy of dizziness and anxiety in the otoneurological setting.
        J Anxiety Disord. 2001; 15: 9-26
        • Kerber KA
        • Brown DL
        • Lisabeth LD
        • Smith MA
        • Morgenstern LB
        Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study.
        Stroke. 2006 Oct; 37 (Epub 2006 Aug 31.): 2484-2487
        • Sloane PD
        • Dallara J
        • Roach C
        • Bailey KE
        • Mitchell M
        • McNutt R
        Management of dizziness in primary care.
        J Am Board Fam Pract. 1994; 7: 1-8
        • Sloane PD
        • Baloh RW
        Persistent dizziness in geriatric patients.
        J Am Geriatr Soc. 1989; 37: 1031-1038
        • Tinetti ME
        • Williams CS
        • Gill TM
        Dizziness among older adults: a possible geriatric syndrome.
        Ann Intern Med. 2000; 132: 337-344
        • Newman-Toker DE
        • Camargo Jr, CA
        ‘Cardiogenic vertigo’—true vertigo as the presenting manifestation of primary cardiac disease.
        Nat Clin Pract Neurol. 2006; 2: 167-172
        • Newman-Toker DE
        • Zee DS
        Building a new model for diagnosis of dizzy patients in the emergency department [abstract BP5.23].
        J Vestib Res. 2002; 11: 281
        • Baloh RW
        Approach to the evaluation of the dizzy patient.
        Otolaryngol Head Neck Surg. 1995; 112: 3-7
        • Sisson SD
        • Walker MF
        Dizziness, vertigo, motion sickness, syncope and near syncope, and disequilibrium.
        in: Barker LR Burton JR Zieve PD Principles of Ambulatory Medicine. 6th ed. Lippincott Williams & Wilkins, Philadelphia, PA2003: 1409-1430
        • Wade NJ
        The search for a sixth sense: the cases for vestibular, muscle, and temperature senses.
        J Hist Neurosci. 2003; 12: 175-202
        • Parker DE
        Spatial perception changes associated with space flight: implications for adaptation to altered inertial environments.
        J Vestib Res. 2003; 13: 331-343
        • Newman-Toker DE
        Charted records of dizzy patients suggest emergency physicians emphasize symptom quality in diagnostic assessment [letter].
        Ann Emerg Med. 2007; 50: 204-205
        • Troost BT
        Dizziness and vertigo in vertebrobasilar disease, part 1: peripheral and systemic causes of dizziness.
        Stroke. 1980; 11: 301-303
        • Sloane PD
        • Linzer M
        • Pontinen M
        • Divine GW
        Clinical significance of a dizziness history in medical patients with syncope.
        Arch Intern Med. 1991; 151: 1625-1628
        • jO'Mahony D
        • Foote C
        Prospective evaluation of unexplained syncope, dizziness, and falls among community-dwelling elderly adults.
        J Gerontol A Biol Sci Med Sci. 1998; 53: M435-M440
        • Mathias CJ
        • Deguchi K
        • Schatz I
        Observations on recurrent syncope and presyncope in 641 patients.
        Lancet. 2001; 357: 348-353
        • Cherian N
        Dizziness. The Cleveland Clinic Disease Management Project.
        (Accessed April 5, 2007.)
        • Rubin AM
        • Zafar SS
        The assessment and management of the dizzy patient.
        Otolaryngol Clin North Am. 2002; 35: 255-273
        • Labuguen RH
        Initial evaluation of vertigo.
        Am Fam Physician. 2006; 73: 244-251
        • Blakley BW
        • Goebel J
        The meaning of the word “vertigo”.
        Otolaryngol Head Neck Surg. 2001; 125: 147-150
        • American Academy of Otolaryngology-Head and Neck Foundation, Inc.
        Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere's disease.
        Otolaryngol Head Neck Surg. 1995; 113: 181-185
        • Samuels MA
        • Harris JR
        The dizzy patient: a clear-headed approach.
        in: Martin RA Family Practice Curriculum in Neurology. McGraw-Hill Companies, Inc, Greenville, NC2001 (Accessed September 21, 2007.)
        • Lawson J
        • Johnson I
        • Bamiou DE
        • Newton JL
        Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a Falls and Syncope Unit.
        QJM. 2005 May; 98 (Epub 2005 Apr 8.): 357-364
        • Kentala E
        • Pyykko I
        Vertigo in patients with benign paroxysmal positional vertigo.
        Acta Otolaryngol Suppl. 2000; 543: 20-22
        • Matsuo T
        • Sekitani T
        Vestibular neuronitis: neurotological findings and progress.
        ORL J Otorhinolaryngol Relat Spec. 1985; 47: 199-206
        • Keim RJ
        Comparison of symptoms and laboratory findings in unilateral vestibular dysfunction.
        Otolaryngol Head Neck Surg. 1984; 92: 577-579
        • Gillespie MB
        • Minor LB
        Prognosis in bilateral vestibular hypofunction.
        Laryngoscope. 1999; 109: 35-41
        • Hughes GB
        • Kinney SE
        • Hamid MA
        • Barna BP
        • Calabrese LH
        Autoimmune vestibular dysfunction: preliminary report.
        Laryngoscope. 1985; 95: 893-897
        • Verstreken M
        • Declau F
        • Wuyts FL
        • et al.
        Hereditary otovestibular dysfunction and Meniere's disease in a large Belgian family is caused by a missense mutation in the COCH gene.
        Otol Neurotol. 2001; 22: 874-881
        • Hakuba N
        • Hato N
        • Shinomori Y
        • Sato H
        • Gyo K
        Labyrinthine fistula as a late complication of middle ear surgery using the canal wall down technique.
        Otol Neurotol. 2002; 23: 832-835
        • Low PA
        • Opfer-Gehrking TL
        • McPhee BR
        • et al.
        Prospective evaluation of clinical characteristics of orthostatic hypotension.
        Mayo Clin Proc. 1995; 70: 617-622
        • Culic V
        • Miric D
        • Eterovic D
        Correlation between symptomatology and site of acute myocardial infarction.
        Int J Cardiol. 2001; 77: 163-168
        • Dieterich M
        • Brandt T
        Episodic vertigo related to migraine (90 cases): vestibular migraine?.
        J Neurol. 1999; 246: 883-892
        • Kayan A
        • Hood JD
        Neuro-otological manifestations of migraine.
        Brain. 1984; 107: 1123-1142
        • Kase CS
        • Norrving B
        • Levine SR
        • et al.
        Cerebellar infarction: clinical and anatomic observations in 66 cases.
        Stroke. 1993; 24: 76-83
        • Fisher CM
        Vertigo in cerebrovascular disease.
        Arch Otolaryngol. 1967; 85: 529-534
        • Yardley L
        • Owen N
        • Nazareth I
        • Luxon L
        Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae.
        J Nerv Ment Dis. 2001; 189: 321-327
        • Jaap AJ
        • Jones GC
        • McCrimmon RJ
        • Deary IJ
        • Frier BM
        Perceived symptoms of hypoglycaemia in elderly type 2 diabetic patients treated with insulin.
        Diabet Med. 1998; 15: 398-401
        • Drachman DA
        • Hart CW
        An approach to the dizzy patient.
        Neurology. 1972; 22: 323-334
        • Shore WB
        Observations from practice with Filipino patients [eLetter].
        Ann Fam Med. 2003; 1 (Accessed September 24, 2007.): 113-118
        • Kerrigan P
        Guidelines for giddiness please [editorial].
        Practitioner. 2000; 244: 61
        • Karunaratne PM
        • Broadhurst PA
        • Norris CA
        Outcomes of permanent pacemaker implantation for carotid sinus hypersensitivity in a district general hospital with a Falls Fits Faints and Funny Turns Clinic.
        Scott Med J. 2002; 47: 128-131
        • Blau JN
        • Spillane JA
        Vertebro-basilar insufficiency and the ENT surgeon, with an approach to the giddy patient.
        Clin Otolaryngol Allied Sci. 1981; 6: 73-78

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