Appointment Preparation and Case History
OVERVIEW
Obtaining case history in the dizziness clinic, whether in-person or via remote (telemedicine), is of diagnostic importance. There is a fine balance between the direct patient interview and fostering a climate of trust. The interview process is often considered part of the “art” of medicine and guides decision making for efficient clinical examination (Lichstein, 1990). Necessary components that should not be overlooked include patient’s values, perspective, and readiness for management (motivational interviewing).
FORMULATING THE CLINICAL QUESTION(S)
The clinical question(s) should be specific to gear the evaluation toward possible answers. While most questions are developed during the case history, some preplanning is warranted to guide the interview questions. An example would be a patient presenting with movement provoked symptoms of dizziness and unsteadiness for one month prior to evaluation. Per medical records, additional associated symptoms and/or neurological complaints are denied. Based on the medical history review, clinical question(s) may include:
• Is benign paroxysmal positional vertigo (BPPV) suspected?
• Is there evidence of uncompensated peripheral vestibular system hypo/hyperfunction?
This review of past medical history aids in developing initial clinical questions, and streamlines the case history. Key components to include in this review are:
• Description of symptoms
• Duration and frequency of symptoms
• Initial onset of symptoms
• Imaging results
• Associated symptoms (e.g., hearing loss, neurological complaints)
• Visual history and current concerns
• Auditory history and current concerns
• History of falls
• Medical problem list or comorbidities
• Family history
• Past vestibular assessment and results
• Past treatment (e.g., physical therapy, medications) and treatment outcome
• Possible medication effects
• Other pertinent information to formulate the clinical question(s)
The use of questionnaires is an invaluable, time efficient resource provided prior to the first appointment (Roland, Sinks & Goebel, 2016). The questionnaire may include elements of the above-listed items to direct the interview process for help rendering diagnosis and management.
PATIENT APPOINTMENT
Building Rapport and Setting Up the Visit Agenda
Prior to discussion of symptoms, it is important to establish rapport and set the appointment agenda:
• Provide clear introductions, verify patient identifiers (e.g., name and date of birth), and determine the patient’s level of comfort
• Confirm patient understanding of the appointment’s purpose. The clinician may need to briefly describe the sensory and motor systems involved in balance control.
• Clarify the goal of the appointment: identification of potential symptom causes.
• Inform the patient that laboratory testing is an indirect means of evaluating the balance system. Additional time may be required for analysis of the test results following the appointment.
After establishing the agenda, ask the patient to verify that pretest instructions were followed if applicable (e.g., no alcohol, no medications for dizziness/motion sickness, no sedatives, and no eye makeup). If the patient did not comply with some or all of the pretest instructions, document within the report.
Case History
Patients may present with primary and secondary symptoms that assist in the differential diagnosis. If significant others are present, establish parameters for their input (Lichstein, 1990). The interview process should be balanced to allow unbiased information from the patient. The clinician role is to facilitate the process while scanning the obtained case history to identify areas needing further clarification. The history should include a synopsis of the patient’s past and present history, extracted from open-ended and refined clinical questions. Technical terms and diagnostic labels should be avoided. Instead, the patient should describe their symptoms and medical history in their own words.
Key Components of the Case History
Order of Events
Patient symptoms may change in character, duration, and frequency from the point of initial onset to the point of evaluation. The chronology of events and initial onset are important, even if years have passed. The examiner needs to define changes in characteristics of the symptoms at the onset vs. the present. Predisposing factors to the initial onset should be identified (e.g., head or neck injury, virus, headache event, change in medications).
Characteristics of the Symptoms
Vestibular symptoms may stem from disturbances within any aspect of balance function (Bisdorff, 2016). A myriad of symptoms may result including dizziness, vertigo, and unsteadiness; however, many other nonvestibular etiologies (e.g., cardiovascular, psychiatric, toxic, or metabolic) may cause similar presentations. Based on the patient’s history, symptoms may be categorized and centered on suspected diagnoses (refer to Appendix A). There are primary symptoms and secondary symptoms that may provide clues for the differential diagnosis (Tables 2–1 and 2–2).
Time Course of Symptoms
Step one is understanding the initial symptomatology within these four categories (or combinations thereof) to determine differential diagnosis:
• Acute/sudden onset: vestibular neuritis/labyrinthitis, acute stroke/transient ischemic attack (TIA), demyelinating disease, post-traumatic vertigo
• Spontaneous/episodic: vestibular migraine, Ménière’s disease, anxiety, medication effects
• Triggered/episodic: benign paroxysmal positional vertigo (BPPV), superior semicircular canal dehiscence (SSCD), orthostatic hypotension, vertebrobasilar insufficiency (VBI), perilymphatic fistula, central positional vertigo
• Chronic (continuous): central nervous system (CNS) lesions, panic disorder, cervicogenic vertigo, metabolic conditions/infections, medication side effects
Table 2–1. Primary Vestibular Symptoms
Note: Oscillopsia may be considered a secondary symptom within the category of vestibulovisual symptoms; however, its distinction from other symptoms (vertigo, dizziness) warrant inclusion as a primary symptom related to vestibular dysfunction (e.g., bilateral vestibular loss).
Sources: Bisdorff, Staab, & Newman-Toker, 2015; Bisdorff, von Brevern, Lempert, & Newman-Toker, 2009.
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