NEURO-OTOLOGIC HISTORY

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

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.

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.

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.

To assess emergency physicians' diagnostic approach to the patient with dizziness, using a multicenter quantitative survey.

We anonymously surveyed attending and resident emergency physicians at 17 academic-affiliated emergency departments with an Internet-based survey (September 1, 2006, to November 3, 2006). The survey respondents ranked the relative importance of symptom quality, timing, triggers, and associated symptoms and indicated their agreement with 20 statements about diagnostic assessment of dizziness (Likert scale). We used logistic regression to assess the impact of “symptom quality ranked first” on odds of agreement with diagnostic statements; we then stratified responses by academic rank.

Of the 505 individuals surveyed, 415 responded for an overall response rate of 82%. A total of 93% (95% confidence interval [CI], 90%-95%) agreed that determining type of dizziness is very important, and 64% (95% CI, 60%-69%) ranked symptom quality as the most important diagnostic feature. In a multivariate model, those ranking quality first (particularly resident physicians) more often reported high-risk reasoning that might predispose patients to misdiagnosis (eg, in a patient with persistent, continuous dizziness, who could have a cerebellar stroke, resident physicians reported feeling reassured that a normal head computed tomogram indicates that the patient can safely go home) (odds ratio, 6.74; 95% CI, 2.05-22.19).

Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated symptoms) appear relatively undervalued. Educational initiatives merit consideration.