Magnetic resonance imaging (MRI) is a technique used to take high-quality pictures of the brain. Learn how to best understand these studies.
Dizziness is among the top three new symptoms that bring people to their doctors. But most people don't know how to describe that symptom. There's at least three different types of dizziness. There's vertigo, which is a false sense of motion like the world is moving around you. There's lightheadedness, which is the feeling you get before you might faint. There's disequilibrium, which means a sense of imbalance. And then there's everything else, as many people use the term "dizzy" to describe tingling, weakness, nausea, fatigue, or dozens of other symptoms. As difficult as describing dizziness can be, doing so is the only way to clue doctors in on the likely cause and thereby the best treatments for your particular type of "dizziness." You can learn more here.
People sometimes confuse the terms "neurologist" and "urologist." While I usually focus on things from the waist up, the nervous system goes all over the body and is involved with everything we do, including using the toilet.
Losing control of our bladder can be embarrassing, and can also be a sign of even more serious problems. Neurologists may become involved when a problem with the brain, spinal cord, or peripheral nerves is thought to underlie the urinary incontinence. The term "neurogenic bladder" is used in this case, but actually describes a wide range of bladder behavior.
The number of people who go to the Emergency Department with dizziness has been climbing, and is one of the major complaints people bring to their doctors. The proportion of patients who get CAT scans for their dizziness is also going up--a recent survey demonstrated that about 30% of those who go to the ER with dizziness get a CT scan. In contrast the maneuver that is most likely to diagnose benign positional peripheral vertigo (BPPV), a very common cause of dizziness, is relatively rarely performed. About 80% of the documents from the ER made no mention of this simple bedside test, which avoids many of the problems associated with radiation and CT scans. Furthermore, more than 95% of documents made no mention of the Epley maneuver that commonly fixes peripheral vertigo due to BPPV. This maneuver has been shown to be effective in over 50% of cases.
Why is this? Is it due to medical templates in which a CT is mentioned? An observational studies shows that templates that don't include this item lead to a 12% chance of getting the scan, lower than the average. Or perhaps the current medicolegal culture of medicine is to blame. While radiation can increase the risk of cancer in the long run, it usually takes several years to develop that cancer--longer than a courtroom would generally consider to be reasonable evidence of causality or harm. A bleed in the brain, however rare, would be more directly traced to the doctor if missed. In this case, the legal system designed to protect patients could actually be contributing to further harm.
Efforts to change inappropriate use of CT scans in diagnosing dizziness are underway. A trial is being done to try to get people to change their behavior, so that the proper tests and treatment are prescribed in the ER. In the meantime, a method called HINTS seems to do a better job even than early MRI scans in determining whether someone's acute dizziness is due to stroke, with 100% sensitivity and 96% specificity. HINTS stands for: head-impulse, nystagmus, and test-of-skew. These are three physical exam techniques, which, in combination, can very effectively guide how concerned a doctor in the emergency room should be when someone presents with dizziness. Certainly this is more effective than a CT, then, which are not great at looking at the bottom of the brain, where a subtle lesion causing dizziness would most likely be located...
AA Tarnutzer, AL Berkowitz, KA Robinson, YH H, DE Newman-Toker. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ June 14, 2011, 183(9)
JC Kattah, AV Talkad, DZ Wang, YH Hsieh, DE Newman-Toker. HINTS to diagnose stroke in the acute vestibular syndrome. Three-step bedside oculmotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 50:3504-3510
Many people find the end of anyone's life is an uncomfortable topic. Nevertheless, death is one thing that is certain to all of us, and since doctors are often responsible for helping that death be as comfortable and dignified as possible, I am obligated to ask delicate but critical questions about the end of life.
Whether someone would want to be resuscitated using chest compressions or not, whether someone would want to be intubated, whether they would want an autopsy, whether they had discussed organ donation with their family--all of these things are intensely personal decisions, and I want to do my best to ensure that whatever their beliefs, they are respected.
In order for someone's wishes to be respected after death, it is important that these topics be discussed with family members and medical professionals as well as documented. Simply checking the organ donation box on a driver's license application may be insufficient, for example, if family members strongly disagree. As morbid as the conversation may be, it must be held prior to serious illness. Doing so can spare friends and families an agonizing disagreement about what you would have wanted were you able to decide for yourself.
In addition to death, many people fail to consider the possibility that they will one day be unable to make decisions for themselves. Whether due to the slow progression of dementia or a sudden traumatic brain injury, people can and lose their ability to make good decisions. Arranging a living will and discussing issues such as power of attorney can ensure that your wishes are respected and can help avoid family debates about what you would have wanted if you were able to speak for yourself.
To begin, you can read these articles: