Lecture Notes: SO STONED - A Common Sense Approach to the Dizzy Patient

Abstract

• History taking is crucial for diagnosing vertigo.
• Key diagnostic factors: time profile, symptom profile, trigger profile.
• "SO STONED" mnemonic: Symptoms, Often, Since, Trigger, Otology, Neurology, Evolution, Duration.
• Helps identify vestibular disorders by their fingerprints across these dimensions.

Introduction

• Vertigo and dizziness have a 7.4% lifetime prevalence.
• Correct diagnosis requires targeted history, clinical exams, testing, and imaging.
• The 2-minute HINTS test distinguishes between peripheral vestibular lesions and central pathologies (stroke).
• The SO STONED tool structures essential history information for diagnosis.

SO STONED Framework

Dimensions and Questions

• Symptoms (S): Types of vertigo symptoms like nausea, instability, lightheadedness.
• Often (O): Frequency of occurrences - daily, weekly, monthly, etc.
• Since (S): Duration of the problem and its onset circumstances.
• Trigger (T): Activities or situations inducing symptoms.
• Otology (O): Ear-related symptoms like hearing loss, tinnitus.
• Neurology (N): Neurological symptoms like headaches, paresthesia.
• Evolution (E): Progression of symptoms - persistent, improving, or worsening.
• Duration (D): Length of symptoms - seconds to continuous.

Vestibular Disorders Classification

• Classified as acute, episodic, or chronic vertigo.
• Examples include:
  • Acute Vertigo: Vestibular neuritis, stroke.
  • Episodic Vertigo: BPPV, Meniere’s Disease, Vestibular migraine.
  • Chronic Vertigo: PPPD, Bilateral vestibulopathy.

Detailed Explanation of SO STONED Dimensions

S: Symptoms

• Focus on specific vertigo-related complaints.
• Different symptoms suggest different underlying issues.

O: Often

• Frequency of attacks is diagnostic (e.g., BPPV daily, MD weekly/monthly).

S: Since

• Time of onset and past events help pinpoint cause.

T: Trigger

• Activities/situations causing symptoms (e.g., head movements for BPPV).

O: Otology

• Ear-related symptoms can indicate specific disorders (e.g., tinnitus in MD).

N: Neurology

• Identifies central vs. peripheral causes based on neurological symptoms.

E: Evolution

• Tracks symptom progression, useful for differential diagnosis.

D: Duration

• Helps exclude specific conditions (e.g., MD cannot last seconds).

Conclusion

• SO STONED aids systematic history taking for vertigo.
• Facilitates differential diagnosis of vestibular disorders.

Contributions

• Developed by FW, with insights from VR and LM.

Acknowledgments

• Thanks to Adolfo Bronstein, Imperial College, London.