This document provides an overview of the medical approach to evaluating and diagnosing dizzy patients. It begins with an introduction to dizziness and vertigo. The evaluation involves taking a thorough history, performing a physical exam including tests like the Dix-Hallpike maneuver, and ordering relevant paraclinical tests. Differential diagnoses are categorized as non-systematized dizziness or vertigo, which can have peripheral or central causes. Peripheral causes of vertigo include benign paroxysmal positional vertigo and vestibular neuritis. Central causes involve the brainstem or cerebellum.

1. Medical Approach to DizzyMedical Approach to Dizzy
PatientsPatients
By : Naveen MalikBy : Naveen Malik
INDUSTRY HEALTH CENTERINDUSTRY HEALTH CENTER

2. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

3. INTRODUCTION
• Dizziness is the third most common
complaint among all outpatients.
• The single most common complaint
among patients older than 75 yrs.

4. CATEGORIZING DIZZINESS
• Pre-syncope/dizziness
• Syncope
• Disequilibrium
• Psychogenic
• Vertigo

5. DIZZYNESS/VERTIGO
• Dizziness - includes lightheadedness, motion
intolerance, imbalance, floating or vertigo.
• Vertigo - Illusion of motion interpreted as self
movement or environmental movement
• Rotating with spinning sense of falling or
swaying back and forth
• 1/2 of patients with dizziness have vertigo

6. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

7. History
• Does the patient experience a spinningspinning
sensation? This sensation is classic for true
vertigo (vestibular end organs, vestibular
nerve, vestibular nuclei).
• Is the patient experiencing nausea and
vomiting? (usually have labyrinthine disease)
• Are any associated auditory symptomsauditory symptoms
present?

8. • What is the timing of the dizziness? Does it
completely resolve between attacks?
• Are any neurologic symptoms associated with the
dizziness? (also visual)
• Drug history – e.g. phenytoin
• Past medical, surgical, family, psychiatric history and
social history.
– Vascular problems, such as coronary artery disease or
carotid artery disease, suggest certain causes of dizziness.
– Headaches may suggest migraine-associated dizziness…

9. DRUGS

10. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

11. Physical Examination
• Blood pressure (check for orthostatic) & PR
and Heart Rhythm (ECG).
• Ear  otoscopy, audiogram.
• Eye  fundoscopy, iris reactivity, motion,
Saccadic and persuade examination.
• Complete cranial nerve (CN) evaluation.
• CVS → Auscultate the heart and carotids.

12. • Evaluate the balance function:
– Head-thrust and head-shake tests
– Dix-Hallpike maneuver (A positive result is
suggestiveBPPV)
– Fistula test (perilymph fistulas)
– Cerebellar function should be assessed
(finger-to-nose and heel-to-shin, Gait should
be observed)
– Romberg test (proprioceptive)

13. Dix-Hallpike Maneuver:Dix-Hallpike Maneuver:

14. Head thrust test

15. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

16. Para-clinical Issues
• Hemoglobin and hematocrit levels.
• Thyroid function tests (T4 and TSH).
• Fasting glucose.
• Cholesterol levels.
• Rheumatoid factor.
• Tests for syphilis (FTA-ABS and VDRL).

17. • Radiographic imaging:
– in patients with suspected retrocochlear
abnormalities
– in patients who demonstrate equivocal results in
other studies
– all patients who have new-onset vertigo or
neurologic findings (although not indicated in
younger patients who have a clear peripheral
cause)
MRI , Brain CT,…

18. • Audiometery: in all patients.
• Electronystagmography It’s standard of
objective assessment of vestibular function.
– ENG provides the examiner with information
regarding the site of the lesion
– If the patient’s nystagmus is worsened by fixation,
a central focus of a pathologic condition should be
suspected.

19. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

20. Differential Diagnosis
• Nonsystematized dizziness
• Vertigo
– Peripheral
– Central
Vertigo: …Sense of motion. These symptoms are generally brought
on by disturbance to the vestibular end organs and the
retrocochlear pathways

21. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

22. Nonsystematized dizziness
• Proprioceptive system abnormalities
– Pt. May have Ataxia too
• chronic alcoholism
• Vitamin deficiencies due to malnutrition
• Pernicious anemia
• Syphilis (tabes dorsalis)

23. • Eye abnormalities
– If visual compromise is suspected, tests for visual
acuity should be performed
– Complaints of diplopia should be investigated
– In glaucoma often complain of dizziness is
secondary to visual change

24. • Infection
– Meningitis, encephalitis, syphilis
• Tumors:
– Tumors affecting the cochlea and retrocochlear
pathways
– Tumors in other parts of the CNS often present
with nonspecific dizziness

25. • Trauma
• Metabolic abnormalities
– thyroid dysfunction
– pregnancy
– Menstruation
– Exogenous hormones
– Hypoglycemia
• Migraines
• Epilepsy

26. • Psychogenic (chronic anxiety):
– Complaints are often vague, numerous, and out of
proportion to the physical findings.
– They are frequently associated with brief episodes
of dizziness, nausea, shortness of breath, chest
tightness, paresthesias, and diaphoresis.

27. Presentation OutlinesPresentation Outlines
IntroductionIntroduction
HistoryHistory
Physical ExaminationPhysical Examination
Para-clinical issuesPara-clinical issues
Differential DiagnosisDifferential Diagnosis
– Non-systematized DizzinessNon-systematized Dizziness
– VertigoVertigo
• PeripheralPeripheral
• CentralCentral

28. Peripheral or Central Cause?
Peripheral
• Labyrinth or vestibular
nerve dysfunction
• Recurrent
• Nystagmus-horizontal
• Position change
• Moderate to severe
vertigo
Central
• Cerebellum or brain
stem dysfunction
• Continuous
• Nystagmus-vertical
• Mild vertigo
• Non-positional

29. PERIPHERAL CAUSES

30. • Benign paroxysmal positional vertigo (BPPV)
– patients report attacks caused by turning in bed or
watching traffic while sitting in a car.
– This condition is fatigable. generally have a
positive Hallpike maneuver .
– Antihistamines tend to decrease the symptoms
but should be used minimally because they delay
the process of fatigue.

31. Epley maneuver – 90% successfulEpley maneuver – 90% successful

32. • Vestibular neuritis
– a complication of an upper respiratory tract
infection.
– The virus is postulated to affect the vestibular
nuclei and causes sudden and severe vertigo,
nausea, and vomiting.
– The attacks are sudden and generally resolve after
a couple of weeks. Auditory symptoms areAuditory symptoms are
absentabsent..
– treatment centers around bed rest and
pharmacologic suppression of the vestibular
symptoms and Cotricosteroids.

33. • Endolymphatic hydrops
– The most common form of endolymphatic hydrops
is Meniere’s diseaseMeniere’s disease.
• The vertigo minutesminutes to an hourto an hour and may persist for
up to several hours.
Meniere’s

35. – Although the disease starts unilaterally, up to 40%40%
of patients may develop bilateral auditory
symptoms.
– Medical Treatment:Medical Treatment: Greater than 90% of patients
with Meniere’s disease respond well to medical
management:
• restrict daily salt intake to 1.5 g/d
• Avoid Smoking and caffeine
• Diuretics
• Vestibular suppressants (dimenhyrinate,…)
• Acute attacks: Hospitalization, Promethazine,
Diazepam, Antiemetics, rehydration.

36. CENTRAL CAUSES

39. REFRENCES:
• http://www.webmd.com/brain/vertigo-symptoms-causes-treatment
• http://www.emedicinehealth.com/vertigo/article_em.htm
• https://en.wikipedia.org/wiki/Vertigo
• Blue print family medicine textbook