Peter Johns M.D.

Check out my new video of how the nystagmus of vestibular neuritis changes with time, and one way you can avoid missing subtle nystagmus. youtu.be/CE20azV9o-U

@nirmalregency 3PV, so it can be confused with 3PD? (vs BPPV and PPPV, also confusing). Why not think outside the box and call it ODD? (Otoconia Displacement Disease)? Shorter, easier to say the acronym and the long version. and describes the pathology.

3PV

Michael Strupp is gracing our town tomorrow. I have closed my evening clinic. #Vertigo

@BriooSwavey @amrezy You don't seem to know too much about vertigo.

@amrezy And so people know, vertigo, and the spins are TWO DIFFERENT THINGS. Vertigo is something wrong with the fluid in your inner ear, the spins are alcohol intoxication. Two different things.

To think people will risk experiencing vertigo just to get drunk is insane to me

@FlyteXmedical And fatiguing is often used incorrectly to describe the duration of the nystagmus. And it has nothing to do with visual fixation suppressing nystagmus. See my video. youtube.com/watch?v=u_sgcf…

@FlyteXmedical If you see the characteristic nystagmus in BPPV, repeating the DHT is no longer recommended. Just do the Epley. See Bhattacharya 2017 Clinical Practice Guidelines BPPV (Update)

Dizzy in the ED. Central or Peripheral? 🌀🧠 In Emergency Medicine the stakes for vertigo are high. You aren't just treating symptoms - you're ruling out a stroke. Here is the FlyteX Clinical Cheat Sheet for the two most critical tools in your arsenal. 1️⃣ HINTS Exam (The Stroke Rule-Out) 🚨 Used for Continuous vertigo. It is actually more sensitive than an early MRI for identifying a central cause. — Head Impulse: Normal is bad (suggests Central). Abnormal suggests Peripheral. — Nystagmus: Direction-changing or purely vertical is bad (Central). — Test of Skew: Vertical misalignment is bad (Central). 2️⃣ Dix-Hallpike Manoeuvre (The BPPV Rule-In) 🛋️ Used for Episodic vertigo triggered by movement. — Positive: Latent, paroxysmal, torsional nystagmus that fatigues. This confirms BPPV. — Red Flag: If the nystagmus is non-fatiguing or purely vertical, look for a Central cause. #FRCEM #FlyteX

@FlyteXmedical Ah, I see you website is about how to pass an exam, not to clinical practice. Now I get it.

Absolutely agree that HINTS has important limitations and should only be applied in the appropriate patient group 👍 But I think most of us learned medicine using notes, frameworks, acronyms and “cheat sheets” at some stage. The goal is safe understanding and progression - not pretending we all emerged fully formed on day one 📚🩺

@TaniaLe89811601 @nightrider20244 How long does the intense dizziness last for? This sounds like BPPV, which is usually easily treated.

@nightrider20244 Mines a vertigo issue. When I lay down I go into spins. If I roll over im fucked. Takes me all.fay to get over & then it starts again when I go to bed.

Waking up at 3am is not good o give up trying to get back to sleep at 4am

@hjluks How can you tell if you're in the early stage of tendinopathy vs early stages of frozen shoulder. If early frozen shoulder you advise IA steroid injection, but not so much for early tendinopathy.

The Frozen Shoulder... a thread. A frozen shoulder is one of the most misunderstood conditions in orthopedics. It is not purely a mechanical problem. It is a metabolic one. The shoulder capsule becomes a target of systemic inflammation, hormonal disruption, and glycemic dysfunction. Most people, and some surgeons, still treat it as if something is stuck and just needs to be loosened... Properly managing this and the contributors is essential to resolving it.

@nagor76 @hjluks Usually in both shoulders. Frozen shoulder is thankfully unusually only one.

@hjluks Polymyalgia rheumatica (PMR)is also a common cause of shoulder pain. Consider a consult with a rheumatologist.

X Ortho 101 is in session on a Saturday... The Frozen Shoulder. Tune in... you might learn something about this miserable disease process. Let's go...

@OttersParlance @GaltMD @DrCasteelEM HINTS is very useful if you have been trained to use it on the right patient, and perform and interpret it correctly. Unfortunately, that's the minority of doctors at the moment. Go to vertigocourse.com to learn how to properly assess the acutely dizzy patient.

@GaltMD @DrCasteelEM HINTS exam? emra.org/emresident/art…

Aortic dissection. Mainly bc symptoms can be completely vague and not anything like “classic” or “textbook” symptoms that AI would miss many of them, 30-40% of them are missed initially and high mortality.

@GaltMD @DrCasteelEM That is a defeatist attitude. Learn how to definitively diagnose BPPV and vestibular neuritis and thus rule out stroke, and you will be a happier clinician, and your patients will be happy too.

@DrCasteelEM Posterior stroke. Nothing you can do in the ED to protect yourself from these cases other than admit everyone over 40 with vertigo.

@sciqst @JAMA_current What could possibly more effective than repositioning maneuvers for those suffering from a new onset of BPPV? It's one of the most effective treatments in all of medicine!

Understanding BPPV is crucial, as it affects many during their lifetime. The insights on symptoms and risk factors from JAMA are valuable. Have treatments evolved in recent years, or are we still relying mostly on repositioning maneuvers? For those living with BPPV, how effective are lifestyle adaptations? #Medicine For further exploration of biomedical topics, check out Sci-Quest, where you can generate comprehensive biomedical reviews: sciqst.com.

Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder that causes brief episodes of vertigo. This JAMA Patient Page describes common symptoms and causes of benign paroxysmal positional vertigo, risk factors, and diagnosis and treatment. ja.ma/41Qv3Us

@whitfieldlewis6 The 37 year old paper by Herr outlines an approach that modern vertigo experts are trying their best to stop people from using. I explain it more in this video. youtube.com/watch?v=V1ZRHV…

2️⃣ Step one is HISTORY and PHYSICAL. Start with an open-ended question: “What do you mean by dizzy?” If they struggle to describe it, dig deeper with targeted questions. Let’s walk through the buckets of the dizzy differential. 3️⃣ Here’s a classic breakdown from the ED (Herr et al. 1989): Top causes: Vertigo Psychiatric Presyncope Central causes (e.g., stroke) Hyperventilation Unknown Each one requires a different line of questioning.

Tweet thread 🧵🧵🌀 “Doc, I’m dizzy…” What does that even mean? To the patient, dizziness is vague. To you, it’s a diagnostic challenge. 1️⃣ First, remember: The patient in front of you isn’t a neurologist. Their vocabulary isn’t going to include “vertigo,” “presyncope,” or “disequilibrium.” All they know is: “Doc, I feel dizzy.” Your job is to translate that into a differential. Let’s break it down. 🧵👇👇

@NightShiftMD Thanks, Brian! And I just noticed I made a mistake, it’s 9 million views ha ha.

If you want to learn about vertigo and how to manage it, you must follow @PeterJohns84

Maybe the world does care about vertigo! Just hit 35k subscribers, 8 million views to my youtube channel. @PeterJohns" target="_blank" rel="nofollow noopener">youtube.com/@PeterJohns

@ETtube Yes, AVS and HINTS.

@PeterJohns84 Peter are you presenting?

If you think you have diagnosed bilateral BPPV before, but you have never diagnosed horizontal canal BPPV, well, you've missed a bunch of HC BPPV patients. youtu.be/VRjRTnIw9YE