Dizziness is impairment of spatial perception and stability and can be classified as vertigo, presyncope, or disequilibrium.

Differential Diagnosis

Differential Diagnosis: (MIDS)


  • Benign Paroxysmanl Positional Vertigo (BPPV)
  • Vestibular neuritis
  • Meniere disease
  • Otosclerosis
  • Vestibular migraine Cerebrovascular disease
  • Cerebellopontine angle and posterior fossa meningiomas
  • Arrhythmia-Brady/Tachy
  • Sick Sinus
  • AV Block
  • Acute coronary syndrome
  • Hyper/Hypoglycemia
  • Hyper/Hypothyroidism
  • Hyper/Hypothermia
  • Hypoxia
  • CHF
  • Anxiety
  • Orthostatic hypotension/hypovolemia
  • Dehydration
  • Diabetic neuropathy


  • Sepsis
  • Encephalitis
  • Meningitis
  • Vestibular neuronitis


  • Antiarrhythmics
  • Anti-Parkinson’s
  • Anti-hypdertensives
  • Benzodiazepines
  • B-Blockers
  • Ca-Channel Blockers
  • Caffeine
  • Alcohol intoxication or withdrawal
  • Narcotics
  • Vasodilators
  • Hyper/Hypokalemia
  • Diuretics
  • Antidementia agents
  • Antiepileptics
  • Dipyridamole
  • Skeletal muscle relaxants
  • Urinary anticholinergics
  • Lithium
  • Digitalis glycosides
  • Antithyroid agents
  • Anticoagulants


  • Cardiac Tamponade
  • Impacted Cerumen
  • Pneumo/Hemothorax
  • Primary autonomic failure (MS, Parkinsons)
  • Stroke/TIA

History taking

  • Follow the OPQRST questions
  • Ask about duration of the condition
  • Sequence of events- triggers, loss of consciousness
  • Asks about relations to posture
  • Ask about recent falls
  • Ask about losing consciousness
  • Associated symptoms:
    • Pallor, diaphoresis, SOB, Chest pain, palpitation, fever/chills,
  • Rule out vertigo: Feel like you are spinning or that the room is?
  • Rule out syncope or pre-syncope: do you feel like you might black out or you black out?
  • Ask about feeling unsteady on their feet or have difficulty maintaining their balance (disequilibrium)
  • Is there any history of previous similar events?
  • Are you using any medications, herbal products or substance?
  • Ask if there was any recent change in medication or dosage
  • Do you drink alcohol?
  • Ask if client noticed any weakness in limbs
  • Ask if there is any change in bowel or bladder habits
  • Ask about smoking
  • Ask about dietary habits
  • Ask if client do any exercise
  • Ask about home or workplace stress

Past Medical history

  • Ask about similar episodes in the past
  • Ask about past medical problems (DM, A-fib/arrhythmia, Migraine, Mennier’s Disease, or stroke or cardiac problems)
  • Ask about previous hospitalizations

Review of systems

  • General: recent weight loss, fever/chills, built, energy level, skin turgor
  • ENT: Meniere’s, ear wax, hearing, eye problem
  • CNS: headache, weakness, balance/mobility, tremors, head injury
  • CVS: palpitation, chest pain, SOB,
  • GI: nausea/vomiting, diarrhea,  blood in stool

Physical exam

  • Explain to patient what you are going to do
  • Obtain their consent
  • Wash your hands
  • Check vital signs: postural vital signs
  • Observe general status: skin color/warmth, level of distress, pallor, diaphoresis, cap refill,
  • HEENT exam: examine vision, hearing, ear canals
  • CVS- S1 S2, murmurs, respiratory crackles, pedal edema, peripheral pulses
  • Neurological  exam- Cranial nerves, Cincinnati scale to r/o stroke,  Dix-Hallpike maneuver
  • The Dix-Hallpike maneuver is the gold standard test for the diagnosis of posterior canal BPPV
  • Caloric test

Laboratory work up

  • CBC for anemia
  • Electrolytes
  • eGFR
  • ECG for arrhythmia, SVT, conduction delays, …
  • Urinalysis: for infections, sepsis, …
  • Urinary pregnancy: for hemodynamic instability
  • Urinary drug screen if needed

Diagnostic tests

  • CT head if indicated
  • Puretone Audiometry (PTA)


  • Dizziness is a symptom therefore treatment should be directed toward resolving the underlying causes and removing identified triggers.
  • Emergent care if acute stroke
  • Adequate hydration
  • Metoclopramide 5-10 mg po or IM QID
  • Prochlorperazine 5-10 mg po or IM, QID
  • Meclizine, 12.5 to 50 mg orally every 4 to 8 hours
  • Meniere’s disease:
    • Salt restriction
    • Droperidol
    • Diazepam
    • Dimenhydrinate
    • Diphenhydramine
    • Meclizine
    • Anti-vertiginous medications, anti-emetics, sedatives, antidepressants, and psychiatric management have been reported to be beneficial in reducing the severity of vertigo and vegetative symptoms and in improving tolerance of Meniere’s symptoms.
    • Betahistine dihydrochloride 16 mg TID for 2-3 months
  • Vestibular neuritis:
    • Prednisone 60-80 mg PO x4 days taper dose over next 10 days
    • Dimenhydrinate 50 to 100 mg every 6 hours
    • Carbamazepine or Cxcarbazepine
    • Promethazine 25 to 50 mg are often required every 4 to 6 hours
  • Vertigo (BPPV)
  • Antihistamines- Benadryl 50 mg PO Q4-6 hr
  • Betahistine (H1 agonist and H3 antagonist) 8-16mg TID
  • Dix-Hallpike maneuver(diagnosis and treatment)
  • Refer to ENT or neurologist for otoconia repositioning procedure(Epley maneuver)


  • Keller, K.B., Sabatino, D., Winland-Brown, J., Porter, B. O. (2015). Cardiovascular problems. In L. Dunphy, J. Winland-Brown, B. Porter, & D. Thomas.Primary care the art and science of advanced nursing practice (4th ed.) (pp.430-432). Philadelphia: F.A. Davis Co.
  • Graham M.R. (2013). Neurological problems. In C.R. Uphold & M.R. Graham. Clinical guidelines in family practice (5th ed). (pp.906-910).Florida: Barmarrae Books Inc.
  • Cummings CW, Flit PW, Haughey BH, Robbins KT, Thomas JR, Harker LA, et al., editors: Cummings Otolaryngology: Head and Neck Surgery, 4th ed. Mosby, Inc.; 2005.
  • Karlberg M, Annertz M, Magnusson M. Acute vestibular neuritis visualized by 3-T magnetic resonance imaging with high dose gadolinium. Arch Otolaryngol Head Neck Surg. 2004 Feb; 130 (2):229-32.




  • Infection of hair follicle
  • Types:
    • Superficial Pustular Folliculitis:
      • Aka follicular impetigo or Bockhart impetigo
      • Site; Face, Perioral
    • Folliculitis barbae:
      • Commonly in 20-40 years of age
      • Sycosis barbae: Most severe type of this kind
      • +/- Marginal Belpharitis and conjunctivitis
    • Perifolliculitis capitis:
      • Fluctuating
      • Interconnecting nodules
      • Susceptible to 2nd bacterial/Fungal infection
    • Folliculitis keloidalis nuchae, aka acne keloidalis
    • Actinic folliculitis:
      • 24 hrs after exposing to sunlight
    • Malassezia folliculitis:
      • Small
      • Scattered
      • Itchy
      • Follicular papules
      • Mostly on the back, chest, posterior arms and +/- neck
      • Slowl growth and finally becomes pustular
    • Epidermal Growth Factor Receptor (EGFR inhibitors) induced folliculitis
      • Eg: Gefitinib, Cetuximab
      • 1-3 weeks after administering the medication


  • Chronic Cellulitis
    • Mostly between 16- 25 y
  • African Descent
  • Gender: Men more severe on Average
  • Prevalence: 45%-83% among African populations


  • Tinea Corporis infection:
  • Pustular Miliaria


  • Idiopathic
  • Ingrowth hair under skin
  • Fungal
  • Bacterial:
    • Staph aureus (Most Common)
    • Pseudomonas aeruginosa (In hot tubs)
  • Skin friction
  • Parasitic
  • Viral
    • HIV => Eosinophilic folliculitis

Risk Factors

  • Adipose gland adjacent to hair follicle occlusion
  • Ingrowth hair under skin
  • Shaving
  • Cutaneous abscess drainage
  • Surgical wound drainage
  • Plastic/plaster dressing
  • Sun Exposure


  • Usually no scaring
  • Furuncles or carbuncles
  • Abscess
  • Painful cysts requiring surgical drainage

Presenting symptoms

  • Most common sites:
    • Head
    • Neck
    • Buttock
    • Trunk
  • Tender in Palpation
  • Pruritus
  • Superficial pustule
  • Inflammatory nodule
  • Hair follicle is seen mostly at the centre of the inflammation
  • Superficial Pustular Folliculitis:
    • Site; Face, Perioral
  • Folliculitis barbae:
    • +/- Marginal Belpharitis and conjunctivitis
  • Perifolliculitis capitis:
    • Fluctuating
    • Interconnecting nodules
    • Susceptible to 2nd bacterial/Fungal infection
  • Actinic folliculitis:
    • 24 hrs after exposing to sunlight
  • Malassezia folliculitis:
    • Small
    • Scattered
    • Itchy
    • Follicular papules
    • Mostly on the back, chest, posterior arms and +/- neck
    • Slow growth and finally becomes pustular
  • Epidermal Growth Factor Receptor (EGFR inhibitors) induced folliculitis
    • Eg: Gefitinib, Cetuximab
    • 1-3 weeks after administering the medication


  • Pain
  • Itching

Red flags

  • Swollen
  • Painful
  • Sever tenderness
  • Fever
  • Sub-cutaneous abscess
  • Immuno-compromised patients
  • HIV +Ve Patients


Lab work ups

  • Diagnosis is mainly through P/E
  • If suspicious to Eosinophilic Folliculitis, R/O Immunosuppression:
    • CBC with diff
  • If suspicious to Fungal cause:
    • KOH smear preparation


  • No imaging required
  • Diagnosis is mainly through P/E and also Hx


  • Eliminate underlying cause:
    • Remove plaster
    • Replace/ remove the plastic dressing
  • Mupirocin topical ointment
  • Aluminum Acetate 1/20 or 1/40 solution
    • Soak 6 layers of gauze in the solution
    • Change dressing q 2-3 hrs
  • Antibiotics:
    • Dicloxacillin: 250-500 mg PO q6h X 10 days
    • Erythromycin: 250-500 mg PO q6hX 10 days
  • Topical steroid creams:
    • Indication: Severe inflammation
  • If eosinophilic folliculitis:
    • Itraconazole: 100-400 mg po qd
    • Anti Retroviral Therapy (ART)
    • Isotertinoin: 40-80 mg/day, 0.5–1.2 mg/kg per day)
    • UVB Phototherapy
    • Permethrine 5% topical cream
    • Topical antihistamines and Corticosteroids


  • Guidelines on the Treatment of Skin and Oral HIV-Associated Conditions in Children and Adults. Geneva: World Health Organization; 2014. 7, Evidence and recommendations on eosinophilic folliculitis. Available from:
  • Sun, K. L., & Chang, J. M. (2017). Special types of folliculitis which should be differentiated from acne. Dermato-endocrinology, 9(1), e1356519. doi:10.1080/19381980.2017.1356519
  • Luelmo-Aguilar J, Santandreu MS. Folliculitis: recognition and management. Am J Clin Dermatol. 2004;5(5):301-10. Review. PubMed PMID: 15554731.
  • Laureano AC, Schwartz RA, Cohen PJ. Facial bacterial infections: folliculitis. Clin Dermatol. 2014 Nov-Dec;32(6):711-4. doi: 10.1016/j.clindermatol.2014.02.009. Epub 2014 Mar 1. Review. PubMed PMID: 25441463.
  • Prasad P, Anandhi V, Jaya M. Chronic folliculitis – A clinico-epidemiological Indian J Dermatol Venereol Leprol. 1997 Sep-Oct;63(5):304-6. PubMed PMID:  20944361.






  • Tissue injury because of freezing
  • The level of involvement is like an iceberg!


  • Annual incidence: 1.1 %
  • Gender: Men > Women (A little more)
  • Mean age: < 65 (Frequency diminishes after this age)
  • Most targeted population:
    • Occupational groups
      • Skilled agricultural
      • Fishery workers
      • Craft
      • Related trades workers
      • Plant and machine operators
      • Assemblers
      • Echnicians
      • Associate professionals



  • Tissue injury (Vasoconstriction => Tissue hypo-perfusion => Tissue ischemia => Necrosis => Gangrene) because of freezing and extreme cold mostly in high altitudes

Risk factors

  • Exposing a bare skin (Unprotected) to extreme cold and freezing condition for reasonable amount of time
  • Working in certain industries
  • Weekly cold exposure at work
  • Individual risk factors:
    • Diabetes Mellitus
    • White fingers in the cold
    • Cardiac insufficiency
    • Angina pectoris
    • Stroke
    • Depression
    • Heavy alcohol users
    • Homeless
    • Hunters
    • Bikers
    • Babies sleeping in cold room temperature
    • Elderlies with no good support


  • Rewarming causes enormous pain
  • Necrosis
  • 2nd bacterial infection
  • Superimposed Cellulitis
  • Local vasoconstriction and tissue ischemia
  • Tissue necrosis
  • Tissue gangrene
  • +/- Auto-amputation
  • Compartment syndrome
  • Prolonged neuropathic symptoms
  • Complex regional pain syndrome


  • Cold skin
  • Erythematous skin
  • Numb skin
  • Pain
  • Shivering
  • Exhaustion
  • Slurred speech
  • Decreased level of consciousness
  • Drowsiness
  • Confusion
  • Fatigue


  • Most common sites:
    • Exposed skin
    • Distal of upper and lower extremities
  • Skin numbness
  • Swollen
  • Hypothermic skin
  • +/- White skin
  • +/- Blisters
    • Clear serum: Indicates superficial damage (Better prognosis)
    • Contains blood: Indicates deeper level of damage and worse prognosis

Red flags

  • Frost bite is can be similar to burn and both act like an iceberg
  • When rewarming begin, patient might develop with a significant severe pain
  • Tissue rewarming may leads to release of inflammatory cytokines in blood steam, Prostaglandins, Thromboxans, which add up to the injury

Lab work ups

  • Diagnosis is mostly by Hx and P/E
  • Lab work up as indicated by history and physical findings and for monitoring the treatment success


  • Diagnosis is mostly by Hx and P/E
  • To assess circulation, tissue viability and address treatment:
    • Radionuclide scanning
    • MRI
    • Microwave thermography
    • Laser-Doppler flowmetry


  • It is an emergency
  • Call 911
  • Remove the wet clothing
  • Administer Opioids: Morphine Sulfate IV prior to rewarming due to severe pain afterwards
  • Quickly rewarming/ immersing the affected tissue in 40-42 C water
  • Local wound management
  • Consult with general surgeon
  • Caution:
    • Do not attempt to rewarm the tissue with a dry warmer. Since the tissue is numb, it can case a secondary burn!
    • Avoid rubbing the tissue
    • Do not use electric blanket for warming
    • Do not walk on an injured tissue
    • If no warm water around, keep the tissue warm by a blanket till help arrives
  • Blister management:
    • Large and serous/ clear blisters: Either drained in a sterile setting or left to be absorbed
    • Hemorrhagic blisters: Left intact=> increase the chance or tissue dissection and 2nd bacterial infection if manipulated
    • Broken blisters: Debridement in a sterile setting
  • Anti-inflammatory topical/Po/IV medications:
    • Aloe Vera topical q6h
    • Ibuprofen 400 mg po q8h
    • Ketorolac 30-60 mg IV
  • +/- Phenoxybenzamine (Alfa- Blocker): 10-60 mg po qd hinders vasoconstriction and increases blood flow
  • Antibiotic prophylaxis: MANDATORY step!
    • Penicillin: To avoid Streptococcal infection
    • In any sign of wet gangrene: broad spectrum antibiotics must be initiated
  • DO NOT forget to administer Tetanus Toxoid! (Vaccination) if the patient’s hx if not reliable, not informative or vaccination is not updated.
    • Act as tetanus vaccination/Toxoid wound injury prophylaxis guidelines
  • Intra tissue pressure measurement: If suspicious to compartment syndrome
  • Consult with a nutritionist for adequate nutrition to keep the metabolism produce more body heat
  • Whirlpool baths:
    • 37 C 3/day
    • Gently dry the tissue after the bath
  • Severe frost bite with gangrene: Emergency consult with general surgeon for possible surgical debridement / Amputation:
    • Do MRI as a helpful indicator to assess the level of injury and need for level of surgical debridement
  • May have a prolonged hospitalization to monitor the level of tissue damage (As previously said, frost bite is like an iceberg and the true level of injury may take several day to weeks to show up!)


  • Mäkinen TM, Jokelainen J, Näyhä S, Laatikainen T, Jousilahti P, Hassi J. Occurrence of frostbite in the general population–work-related and individual factors. Scand J Work Environ Health. 2009 Oct;35(5):384-93. PubMed PMID: 19730758.
  • McIntosh SE, Opacic M, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Dow J, Hackett PH; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S43-54. doi: 10.1016/j.wem.2014.09.001. PubMed PMID: 25498262.
  • Handford, C., Buxton, P., Russell, K., Imray, C. E., McIntosh, S. E., Freer, L., Cochran, A., … Imray, C. H. (2014). Frostbite: a practical approach to hospital management. Extreme physiology & medicine, 3, 7. doi:10.1186/2046-7648-3-7


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Earache, ear pain, otalgia

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