Ohh, you have dizziness, huh? Ohh, you have dizziness again, huh? Ohh, you can't describe what you mean by being dizzy, huh? You just feel dizzy? I get it. You're dizzy but you can't tell me what that means to you. You're just you, know, dizzy. You're not alone. You are like every other American who has ever shown up in the emergency room or as a direct admission from a doctor's office for dizziness. You're just dizzy. That's all you can say. Well, technically, according to the CPT® manual, you have dizziness and giddiness (790.4).
For years, recurrent hospital admissions for dizziness have been a top ten defining characteristic of annoying patients. Annoying mostly because we have nothing to offer in the way of treatment for chronic dizziness inside the magic walls of our magic hospitals. For some folks, chronic dizziness is a chronic pain in the butt for doctors and patients alike.
However, dizziness is such a nondescript symptom. If we are going to try and help patients, physicians must learn to take a detailed dizziness history to try understand exactly what dizziness means to the patient. This is one example of how documenting ROS is not obtainable may actually prevent an accurate diagnosis. As internists, we have been taught to understand dizziness in three broad categories.
Now what? What is a physician supposed to do when their patient doesn't fit nicely in any of these three categories? Most often, what happens next is nothing short of a tragedy. In patients who cannot help their physician define their dizziness and giddiness, the physician's hand has been forced into a very expensive shotgun approach for all three diagnostic trees.
In consideration of all three potential etiologies, your physician may order a head CT, a brain MRI, MRA, carotid dopplers, cardiac echo with bubble study, telemetry, CT angiogram of the chest, lower extremity venous dopplers, tilt table test, lab work including CBC to rule out anemia, electrolyte panel to rule uremia, renal failure and other electrolye disturbances, a d-dimer, a sed rate. They may also get consultation services with a neurologist, cardiologist, ENT and psychiatrist.
And after all that stuff comes back normal, only then will the hospitalist obtain a set of orthostatic blood pressures and discover their symptoms were due to an increase in the lasix dose last week. Unfortunately, when the patient was asked what medications they were on, they said, "It's in my chart". It wasn't in their chart.
After all this nonsense, we're left with an unnecessary admission and thousands of dollars of unnecessary lab, radiology and cardiovascular services being performed because the patient could not define exactly what dizziness meant to them.
But all that changed with creation of a radical new lab test that can be used to diagnose dizziness. First we had the BNP for heart failure. Then came the procalcitonin for sepsis and the perineal plastic panel for cancer. But this new lab test for dizziness promises to revolutionize how hospitalists treat and diagnose dizziness in the hospital. What was this magic new lab test I discovered trascribed in a recent history and physical? I present to you the double stranded dizziness titer. I promise you from the bottom of my heart that this was not a funny transcription error.
That's right folks, my patient is the first patient ever to get a double stranded dizziness titer ordered on them. I had no idea this amazing new dizziness lab test even existed. So I did what every self respecting doctor would do in such a situation. I consulted Google.
There it was, a full explanation of what the double stranded dizziness titer was and how doctors could use this revolutionary new lab test to expedite definitive evaluation and management of a patient's dizziness. The test should only be interpreted with clinical correlation for dizziness. Order the test. If the patient complains of dizziness, the double stranded dizziness titer should be interpreted as positive regardless of what the lab reports as a value. If the patient does not have dizziness, the lab test result should be interpreted as negative regardless of the actual reported value.
Once you have a documented interpretation of a positive double stranded dizziness titer, the physician should order the dizziness antibody sub-titers to further differentiate the etiology of the patient's dizziness. The sub-titers are as follows.
For years, recurrent hospital admissions for dizziness have been a top ten defining characteristic of annoying patients. Annoying mostly because we have nothing to offer in the way of treatment for chronic dizziness inside the magic walls of our magic hospitals. For some folks, chronic dizziness is a chronic pain in the butt for doctors and patients alike.
However, dizziness is such a nondescript symptom. If we are going to try and help patients, physicians must learn to take a detailed dizziness history to try understand exactly what dizziness means to the patient. This is one example of how documenting ROS is not obtainable may actually prevent an accurate diagnosis. As internists, we have been taught to understand dizziness in three broad categories.
- Is the room spinning? Consider a vertigo evaluation
- Is there a component of being lightheaded? Consider a syncope evaluation
- Is there unstable gait or falling to one side? Consider a stroke evaluation
Now what? What is a physician supposed to do when their patient doesn't fit nicely in any of these three categories? Most often, what happens next is nothing short of a tragedy. In patients who cannot help their physician define their dizziness and giddiness, the physician's hand has been forced into a very expensive shotgun approach for all three diagnostic trees.
In consideration of all three potential etiologies, your physician may order a head CT, a brain MRI, MRA, carotid dopplers, cardiac echo with bubble study, telemetry, CT angiogram of the chest, lower extremity venous dopplers, tilt table test, lab work including CBC to rule out anemia, electrolyte panel to rule uremia, renal failure and other electrolye disturbances, a d-dimer, a sed rate. They may also get consultation services with a neurologist, cardiologist, ENT and psychiatrist.
And after all that stuff comes back normal, only then will the hospitalist obtain a set of orthostatic blood pressures and discover their symptoms were due to an increase in the lasix dose last week. Unfortunately, when the patient was asked what medications they were on, they said, "It's in my chart". It wasn't in their chart.
After all this nonsense, we're left with an unnecessary admission and thousands of dollars of unnecessary lab, radiology and cardiovascular services being performed because the patient could not define exactly what dizziness meant to them.
But all that changed with creation of a radical new lab test that can be used to diagnose dizziness. First we had the BNP for heart failure. Then came the procalcitonin for sepsis and the perineal plastic panel for cancer. But this new lab test for dizziness promises to revolutionize how hospitalists treat and diagnose dizziness in the hospital. What was this magic new lab test I discovered trascribed in a recent history and physical? I present to you the double stranded dizziness titer. I promise you from the bottom of my heart that this was not a funny transcription error.
That's right folks, my patient is the first patient ever to get a double stranded dizziness titer ordered on them. I had no idea this amazing new dizziness lab test even existed. So I did what every self respecting doctor would do in such a situation. I consulted Google.
There it was, a full explanation of what the double stranded dizziness titer was and how doctors could use this revolutionary new lab test to expedite definitive evaluation and management of a patient's dizziness. The test should only be interpreted with clinical correlation for dizziness. Order the test. If the patient complains of dizziness, the double stranded dizziness titer should be interpreted as positive regardless of what the lab reports as a value. If the patient does not have dizziness, the lab test result should be interpreted as negative regardless of the actual reported value.
Once you have a documented interpretation of a positive double stranded dizziness titer, the physician should order the dizziness antibody sub-titers to further differentiate the etiology of the patient's dizziness. The sub-titers are as follows.
- The anti-Vrtg titer to evaluate for vertigo
- The anti-Syncp titer to evaluate for syncope
- The anti-Strk titer to evaluate for stroke
- The anti-Vrtg titer: If a patient gets nauseated and complains of the room spinning while turning their head, this test should be interpreted as positive, regardless of what the lab reports. If the patients denies this symptom complex, this test should be interpreted as negative, regardless of what the lab reports.
- The antiSyncp titer: If a patient has normal telemetry, orthostatic blood pressures, normal lab and a normal echo, this test should be interpreted as negative regardless of what the lab reports. If any syncope workup is postive, this lab test should be interpreted as positive, regardless of the actual lab result.
- The anti-Strk titer : If a patient has a negative diffusion weighted MRI of the brain, the anti-Strk titer should be interpreted as negative regardless of what the lab reports. If the MRI is positive for stroke, the anti-Strk titer should be interpreted as postive regardless of what the lab reports.
