The document discusses the evaluation and potential causes of dizziness in patients. It outlines important aspects of the history to obtain including triggers and associated symptoms. Acute causes mentioned include vestibular neuronitis which presents with sudden vertigo, nausea and vomiting that gradually improves over weeks. Recurrent episodic causes discussed are benign paroxysmal positional vertigo (BPPV), migraine, and Meniere's disease. Red flags are also noted that could indicate a posterior circulation stroke requiring further workup.

1. The Dizzy Patient

2. There can be no physician so
dedicated to their art that they do
experience a slight decline of the
spirits when they learn that their
patients chief complaint is of
dizziness

3. • History
– “head rush” or
– “like being on a roundabout”
– Other focal neurological features
– Hearing loss
– If episodic – duration of episodes and provoking features
– If chronic – variability ?

4. • Acute
– Vestibular neuronitis
• Single acute attack of continuous
vertigo often with nausea and
vomiting for several days
• Positive head impulse test,
unidirectional nystagmus
horizontal and rotational
• No other neurological deficit,
furniture walking
• Rx – bed rest, antiemetics for 3
days only and strong
encouragement to mobilise
• Gradual recovery over weeks but
50% will have canal paresis
detectable on vestibular function
testing at 1 year
• Cawthorne cooksey exercises
Head Impulse Test

5. • Red flags (for posterior circulation stroke)
– Normal head impulse
– Can’t walk
– Focal neurological signs
– Hearing loss, abnormal otoscopy
– New headache

6. • Recurrent episodic
– NOT vestibular neuronitis
– BPPV
• Attacks lasting seconds to a
minute
• Positional, turning over in bed
– Migraine
• Attacks lasting 10-30 minutes to
a minute with associated migraine
features
• The commonest cause of
recurrent dizziness we see
– Menieres
• Attacks lasting minutes to several
hours with roaring tinnitus, ear
fullness and unilateral deafness

7. • Dizziness: A practical approach to
diagnosis and management. Bronstein
and Lempert.

8. • Epley (following a positive Dix-Hallpike)
– Youtube (accurate and safe)