Paul is a 32-year-old man who presented with a constant spinning sensation for the last 3-4 days that was exacerbated by head movement but persisted even when still. Physical examination revealed horizontal nystagmus on leftward and rightward gaze lasting 1-2 minutes, as well as increased reflexes. Differential diagnosis included vestibular neuritis versus multiple sclerosis, as MS can cause vertigo in 20-50% of cases lasting days to weeks and may present similarly to vestibular neuritis. Additional findings associated with MS plaques could include cranial nerve abnormalities or cerebellar signs.

1. Dizziness
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Clinical Reasoning

2. Case
STAGE I
Paul is a 32-year-old man who comes to your office complaining of
dizziness.
Question 1: What is the definition of dizziness? How would you
further classify a chief complaint of dizziness?
Dizziness is a term used to describe a range of sensations, such as feeling
faint, woozy, weak or unsteady .

4. Vertigo

6. Likely Less Likely Not very Likely, but not
excluded
1- Vertigo
1.1- Peripheral
1.2- Central
2- Near syncope
3- Light headedness
4- Imbalance

7. Question 3: What additional questions would you ask to further focus your diagnosis?
Time for History Taking !!

10. After a thorough history taking…

11. Detailed questioning reveals that Paul has had a constant spinning sensation for the last 3–4 days. Although head
movement exacerbates the symptom, it is persistent even when he is still.
Paul does not report any ear pain, ear discharge, hearing loss or tinnitus. The sensation of dizziness is not associated with
nausea, vomiting, sweating or palpitations. He does not report headache, speech difficulty, double vision, visual loss,
unexplained motor symptoms such as involuntary muscle contractions, or any muscle weakness associated with the
attack. He denies any falls, trouble in walking or keeping balance. The episode is not associated with any aversion to bright
lights or sounds. He denies any history of similar episodes in the past – even while traveling in a car.
Paul reports that he had a severe upper respiratory tract infection 2 weeks before his visit for which no treatment was
prescribed.
He does not have any disease for which he takes chronic medications and has never taken any antibiotics or chemotherapy.
Frequently, however, he takes an oral combination of paracetamol/orphenadrine (a muscle relaxant) for chronic neck pain;
this pain gets worse when he sits for long hours in front of the computer.
He does not wear eyeglasses or contacts.
He also denies any history of significant headaches or of prior neurologic complaints except for 3 years ago when he had an
episode of poor vision in his right eye that lasted 1 week, and resolved slowly on its own. He was seen by a local physician
who prescribed a medication, but no further tests were done and no specific diagnosis was made.
He gives no history of hypertension, diabetes mellitus, tobacco smoking, atrial fibrillation, or cocaine use. He denies
dyspnea, orthopnea, PNDs, or chest pain and reports good exercise tolerance; he regularly goes to the gym. He has never
experienced any alteration in the level of consciousness. He does not report any history of anemia or anything suggestive
of bleeding from the GI tract (e.g., melena).

12. 1- “constant spinning sensation for the last 3–4 days” tells us:
- Spinning sensation -> vertigo;
- Constant: Vestibular neuritis or central etiology
2- “persistent even when he is still” tells us :
- Not positional dependent vertigo so not bppv
3- “does not report any ear pain, ear discharge, hearing loss or tinnitus” tells us:
- No tinnitus or hearing loss means not Meniere nor labyrinthitis
4- “not report headache” tells us:
-Not migraine
5- “ not report speech difficulty, double vision, visual loss, unexplained motor symptoms such as involuntary muscle contractions,
or any muscle weakness” tells us:
-Most probably not a stroke
6- “severe upper respiratory tract infection 2 weeks before his visit” tells us:
-URI possible vestibular neuritis
7- “episode of poor vision in his right eye that lasted 1 week, and resolved slowly on its own” tells us:
-What disease might cause this???!!
Let’s reflect!

13. Question 4: How does the new information affect the prioritization of the DDx?
Instructions:
Will add (+) to the corresponding box if the presence/absence of the mentioned symptom doesn’t rule out the
disease on our ddx hence keeping it.
Will add (-) to the corresponding if the presence/absence of the mentioned symptom will rule out the disease on
our ddx.

14. Vertigo Pre-syncope Lightheadedness Imbalance
Spinning sensation - - -
- Persistent: lasts hours-days - - -
- Present if stationary and
increases on motion
+ + + +
Visual Loss (self-limited) + + + +
URTI recent + + + +
Orphenadrine
No Nausea vomiting + + + +
No hearing loss or tinnitus + + + +
No brainstem symptoms + + + +
No headache + + + +
No CVD risks + + + +
No sweating palpitations + + + +
No psych problems or sleep + + + +
No abnormal muscle
movements or weakness or
sensations
+ + + -

15. Vertigo Pre-syncope Lightheadedness Imbalance
Spinning sensation + - - -
- Persistent: lasts hours-days + - - +
- Present if stationary and
increases on motion
+ + + +
Visual Loss (self-limited) + + + +
URTI recent + + + +
Orphenadrine + + + +
No Nausea vomiting + + + +
No hearing loss or tinnitus + + + +
No brainstem symptoms + + + -
No headache + + - +
No CVD risks + + + +/-
No sweating palpitations
No psych problems or sleep + + + +
No abnormal muscle
movements or weakness or
sensations
+ + + +

16. Time for the Physical examination !!

19. After a thorough Physical examination…

20. On physical exam his BP is 126/82 mm Hg (sitting) and 120/80 (after standing for 3 min); pulse is 74 bpm; RR is 16 breaths per
minute, and temperature is 37.0°C.
HEENT exam reveals horizontal nystagmus on leftward and rightward gaze that lasts 1–2 minutes. The nystagmus does not
fatigue with repetition of the maneuver. Pupils are equal, round, react to light and accommodation. Dix-Hallpike does not result in
nystagmus.
Cardiac, pulmonary, and abdominal exams are normal.
Neurologic exam reveals normal gait, motor strength, sensation, negative Romberg sign, and intact cranial nerves with the
exception of the nystagmus noted above. His reflexes are somewhat increased (+3 all over). Babinski is absent. His head thrust test
is normal.

21. - “horizontal nystagmus on leftward and rightward gaze that lasts 1–2 minutes”:
Central etiology rule out peripheral cause
- “Dix-Hallpike does not result in nystagmus”:
No BPPV
- “Neurologic exam reveals normal gait, motor strength, sensation, negative Romberg sign, and intact cranial
nerves with the exception of the nystagmus noted above. “:
No cerebellar infarction 
- “Reflexes are somewhat increased (+3 all over). Babinski is absent” :
Confusing :/
Let’s reflect!

26. Vestibular neuritis vs Multiple sclerosis ??

27. Vestibular neuritis vs Multiple sclerosis ??
Multiple sclerosis
It has been reported that vertigo occurs in 20–50% of multiple sclerosis patients. Vertigo usually
lasts days to weeks and symptoms may resemble vestibular neuronitis. Depending on the
location of the demyelinating plaques, the associated findings may vary. Dysfunction of adjacent
cranial nerves (facial numbness, diplopia) or cerebellar signs (severe ataxia) may be present.

30. That was our last clinical reasoning session!!