Examination of the Dizzy Patient
GOAL
The main goal of the history and examination of the patient with dizziness is to determine whether the patient’s dizziness is actually due to lightheadedness, imbalance, or vertigo, paving the way for the most appropriate further investigation and treatment.
PATHOPHYSIOLOGY OF DIZZINESS
Patients may use the word dizzy to describe several different symptoms, including a sensation of lightheadedness, imbalance, or movement (vertigo).
Lightheadedness implies a sensation of impending loss of consciousness, also called presyncope. Episodic lightheadedness suggests episodes of global cerebral hypoperfusion, such as from cardiac causes or orthostatic hypotension.
Imbalance is a sensation of gait instability (disequilibrium) that may range from subtle to severe. Patients may especially interpret their imbalance as “dizziness” when their gait dysfunction is subtle, because they may be unaware that their feeling is really an imbalanced sensation.
Vertigo refers to an illusory sensation of motion. Most patients with vertigo describe a feeling of rotation of the environment or in their head, but vertigo can also include any feeling of movement, such as a feeling of tilting or swaying. Vertigo occurs due to disorders of the vestibular system, either peripheral (the inner ear or the vestibular nerve) or central (brainstem or cerebellum).
TAKING THE HISTORY OF A DIZZY PATIENT
When evaluating a patient with a complaint of dizziness, the main goal of the history is to try to determine what the patient means by “dizzy.” The first step is to simply ask the patient, “What do you mean by dizzy?” Let the patient tell you, in his or her own words, what he or she means, and try to avoid putting words in the patient’s mouth. Additional clues to the cause of dizziness that can be gleaned by the history alone are listed below.
Lightheadedness
Patients with lightheadedness (presyncope) usually can describe their feeling as that of “lightheadedness” or a feeling “like I might pass out.” A history of any of the episodes progressing to true loss of consciousness is further evidence that the patient’s symptoms fit into this category of dizziness.
Ask about any associated cardiac symptoms, such as palpitations or chest pain, although the absence of these symptoms does not exclude a cardiac cause.
Lightheadedness occurring only after standing suggests orthostatic hypotension.
Imbalance
Patients with imbalance as the cause of their dizziness usually can describe their feeling as something like an “off-balanced” or “unsteady” sensation, and they should be symptomatic when standing or walking but not when lying or sitting.
The historical finding of worsened imbalance when standing in the dark (e.g., walking to the bathroom at night) or with eyes closed (e.g., in the shower) suggests proprioceptive dysfunction. Even in the absence of a positive Romberg test, these historical clues are strongly suggestive of proprioceptive problems, such as can occur due to peripheral neuropathies or spinal cord (posterior column) problems.
Vertigo
Patients with vertigo usually can describe their feeling as that of a spinning, moving, or tilting sensation.
Ask about any associated brainstem symptoms, such as double vision, or numbness or weakness of the face or of the extremities. The presence of brainstem symptoms in patients with vertigo is strongly suggestive of brainstem dysfunction (e.g., ischemia) as the cause; their absence, however, doesn’t exclude the possibility of a central (brainstem or cerebellar) cause of vertigo.
Hearing complaints, such as unilateral hearing loss or tinnitus, occurring in association with vertigo suggest a peripheral labyrinthine disorder.
Paroxysmal vertigo brought on by changes in head position, such as when turning, bending over, or rolling over in bed, is highly suggestive of the clinical syndrome of benign paroxysmal positional vertigo (BPPV), which occurs due to the presence of calcium carbonate crystals floating in one of the semicircular canals.
Nausea and vomiting is a nonspecific accompaniment of vertigo and can occur with vertigo of peripheral or central etiologies.
HOW TO EXAMINE THE DIZZY PATIENT
After obtaining the history, you should hopefully have a pretty good idea whether your patient’s dizziness is due to lightheadedness, imbalance, or vertigo. The examination is then performed to find evidence to support or refute your hypothesis and provide further information regarding possible etiologies. Listed below are specific examination elements, depending on your clinical suspicion, that can be helpful.
Lightheadedness
In the patient with episodic lightheadedness, be certain (as in any new patient visit) to obtain your patient’s blood pressure and pulse, and also perform a bedside cardiac examination.
Check lying and standing blood pressure in any patient whose symptoms suggest the possibility of orthostatic hypotension:
Have the patient lie flat in bed for a few minutes, then check the patient’s supine blood pressure and pulse.
Ask the patient to stand. (It’s usually not necessary to check a sitting blood pressure and pulse, unless the patient can’t tolerate the standing position.)Related posts:
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