Initial Evaluation of Dizziness

I am currently on an ENT rotation and thought it would be helpful to post on a confusing and frequently encountered topic: Dizziness.

Dizziness is a common complaint encountered in the primary care setting. However, the term dizziness is very broad. Patients often use the word dizziness to describe vertigo (spinning), disequilibrium (imbalance), or presyncope (lightheadedness). The three main systems involved in dizziness are neurologic, cardiovascular, and ENT, and it is important to determine which system is involved by the history.

The first question to ask to the patient who presents with dizziness is: How long does each episode of dizziness last? This will help to begin narrowing the differential diagnosis. You may need to give your patients multiple choice answers like the ones below: 

• < 5 seconds (Think benign paroxysmal positional vertigo [BPPV], vasovagal, orthostasis)
• < 1 minute (Can also be BPPV, vasovagal)
• 1 – 3 hours (Think Meniere’s disease)
• > 24 hours (Think infection, inflammation, tumor, CNS process) 

Of course, many other disorders can present within the above time frames, but this helps to start narrowing your thinking.

The next questions to ask are about any associated symptoms, such as nausea, vomiting, fever, chills, chest pain, etc. This will further narrow the differential and help you figure out if there might be another simultaneous process going on. Subsequent questions to ask are easy to remember, because they are all symptoms of Meniere’s disease. Ask the patient if there is any tinnitus, hearing loss, fullness in the ear, or pressure in the ear.

The final step to complete the dizziness history is to ask the patient to describe their dizziness. It may be helpful to give the patient examples, like if they feel like they are on a boat (disequilibrium) or merry-go-round (vertigo), or if they feel like they might faint (presyncope). (These examples were shared with me by my preceptor.)

This is a good starting point to evaluate the patient with dizziness. The purpose of taking the history in this manner is to be able to classify the dizziness as vertigo, disequilibrium, or presyncope. Once you have done so it is best to avoid the term dizziness, because it can mean very different things to each individual.

Sources:
Barton, J, and WT Branch, Jr. Approach to the patient with dizziness. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
Miller, Andrew J., and Gerard J. Gianoli. "Dizziness." Expert Guide to Otolaryngology. Ed. Karen H. Calhoun, Mark K. Wax, and David E. Eibling. Philadelphia, PA: American College of Physicians-American Society of Internal Medicine, 2001. 102-31. Print. ACP Expert Guide Series.