Management of the dizzy patient depends on history, bedside clinical examination, and laboratory testing. This chapter covers the first two portions of this evaluation. An accurate history is needed to determine the onset of the problem, description of the symptoms, and, most important, how the symptoms affect the individual's lifestyle. This last element is crucial to obtain because some individuals may have bedside clinical and laboratory evidence of chronic vestibular loss on one side but may be primarily affected by some other cause of dizziness, such as migraine or anxiety. The bedside clinical examination can be used to distinguish peripheral from central vestibular problems, the extent of loss, and how acute the problem may be. Laboratory testing (see Chapter 11) confirms the provisional diagnosis that was based on history and clinical findings, quantifies the degree of loss, provides evidence of central compensation, and shows evidence of an aphysiological component.
The history is by far the most important part of the evaluation. Unfortunately, taking a good history from the start can be extremely tedious, because the patient's complaints are often vague and also can be complicated by anxiety-provoked symptoms. For this reason, I divide the history into those elements that help with the diagnosis and those that lead to goals for management, including physical therapy.
Elements that Help with the Diagnosis
The tempo, symptoms, and circumstances of the patient's primary complaints are the three key items in the history (Table 10-1).
Table 10-1KEY ITEMS IN THE HISTORY OF THE DIZZY PATIENT |Favorite Table|Download (.pdf) Table 10-1 KEY ITEMS IN THE HISTORY OF THE DIZZY PATIENT
|Disorder ||Tempo ||Symptoms ||Circumstances |
|Vestibular neuritis ||Acute dizziness ||Vertigo, disequilibrium, nausea and vomiting, oscillopsia ||Spontaneous, exacerbated by head movements |
|Labyrinthitis ||Acute dizziness ||Vertigo, disequilibrium, nausea and vomiting, oscillopsia, hearing loss and tinnitus ||Spontaneous, exacerbated by head movements |
|Wallenberg's infarct ||Acute dizziness ||Vertigo, disequilibrium, nausea and vomiting, tilt, lateropulsion, ataxia, crossed sensory loss, oscillopsia ||Spontaneous, exacerbated by head movements |
|Bilateral vestibular deficit or >7 days from a unilateral vestibular defect ||Chronic dizziness ||Dizziness, disequilibrium, occasionally oscillopsia ||Induced by head movements, walking. Exacerbated when walking in the dark or on uneven surfaces |
|Mal de débarquement ||Chronic dizziness ||Rocking or swaying as if on a boat || |
Spontaneous while lying or sitting
Rarely occurs while in motion
|Oscillopsia ||Chronic dizziness ||Subjective illusion of visual motion ||Spontaneous with eyes open |
|Anxiety/depression ||Chronic dizziness ||Lightheadedness, floating, or rocking ||Induced by eye movements with head still |
|Benign paroxysmal positional vertigo ||Spells: seconds ||Vertigo, lightheadedness, nausea ||Positional: lying down, sitting up or turning over in bed, bending forward |
|Orthostatic hypotension ||Spells: seconds ||Lightheadedness ||Positional: standing up |
|Transient ischemic attacks ||Spells: minutes ||Vertigo, lightheadedness, disequilibrium ||Spontaneous |
|Migraine ||Spells: minutes ||Vertigo, dizziness, motion sickness ||Usually movement-induced |
|Panic attack ||Spells: minutes ||Dizziness, nausea, diaphoresis, fear, palpitations, paresthesias ||Spontaneous or ...|