Aug

22

With complaints of dizziness, vertigo or disequilibrium, symptoms can be the result of vestibular, neurologic, vascular, psychologic and even orthopedic pathology.  As such, it is not always clear which specialty is appropriate for referral.  In this age of cost awareness and effectiveness, the primary care physician must make important decisions as to the appropriateness and cost-effectiveness of diagnostic procedures and referrals to specialists.  Patient’s complaining of dizziness or disequilibrium without obvious objective signs, for lack of a more specific diagnostic direction, are often referred for MRI/CAT scan imaging studies to rule out the possibility of brain lesions.  The cost effectiveness of this decision deserves scrutiny, as the yield of these studies is very low whereas the sensitivity diagnostic yield of appropriate physical examination in the doctor’s office is very high.  “Balance disorders are common, while brain tumors are rare”.  Prior to the commencement of tests such as MRI, points that need consideration are the likelihood that MRI will provide any relevant diagnostic information and whether the sensitivity of less expensive more diagnostically useful tests can be performed first.  In our office, the goal of the initial office examination is to determine the probable cause of the patient’s symptoms.  A directed history and extensive neurologic physical examination allows for more exacting diagnosis and thus successful treatment.  Unfortunately, in this day of managed care, many providers must succumb to time constraints prohibiting extensive examinations, necessitating referrals to specialists. many providers have succumbed to the five-minute examination, as they cannot afford more time than that to successfully meet their daily patient load In light of this, specialist referral becomes even more of a consideration. Currently, 50% of patients seen in the primary care setting receive no diagnosis for their complaints of dizziness, yet 70% receive a prescription for meclizine, (Antivert).  Meclizine has not been demonstrated to be effective or appropriate in the treatment of chronic disequilibrium, dizziness or imbalance.  It is occasionally effective in reducing nausea associated with vertigo/spinning in some forms of chronic vertiginous disease, however, it is not curative in any way, and in fact interferes with the natural recovery process often worsening matters further.  It is appropriate to state at this time, that you do not need a specialist referral to consult with me in my office.