Mr. J is a 32-year-old man who comes to your office complaining of dizziness.
|What is the differential diagnosis of dizziness? How would you frame the differential?|
The framework for dizziness recognizes that most patients who complain of dizziness are actually complaining of 1 of 4 distinct sensations (Figure 13–1):
The first pivotal step in evaluating the dizzy patient is to clarify the patient's symptom, since each of the above sensations has its own distinct differential diagnosis and evaluation. Therefore, the first and most important question is “What does it feel like when you are dizzy?” At this point, patients must be given enough time, without interruptions or suggestions, to describe their dizziness as clearly as possible. Commonly used descriptions, their precipitants, and differential diagnosis are listed in Table 13–1. The patient's description of the symptom and precipitant helps select the proper sensation, which is crucial to the remainder of the evaluation. The duration of the dizziness is also diagnostically useful.
Diagnostic approach: dizziness.
Table 13–1. Classification and Characteristics of Dizziness. |Favorite Table|Download (.pdf)
Table 13–1. Classification and Characteristics of Dizziness.
|Vertigo||Near Syncope||Dysequilibrium||Nonspecific Dizziness|
|Chief complaint||Spinning or “merry-go-round”||Nearly fainting||Falling Loss of balance||Floating Vague|
Turning over in bed
Looking up to shelf
|Important historical features|
CNS signs or symptoms (eg, dysarthria, ataxia, diplopia, headache, neck pain)
Peripheral symptoms (eg, hearing loss, tinnitus)
History of syncope
Melena or rectal bleeding
Multiple somatic complaints
Feeling down or hopeless
|Key physicalexam findings|
Cranial nerve exam
Orthostatic blood pressure and pulse
Cranial nerve exam
Peripheral: BPPV, Vestibular neuritis, Meniere disease
Central: CVA, MS, cerebellar hemorrhage, migraine, brainstem tumors
Multiple sensory deficits
Cerebellar degeneration or stroke
Generalized anxiety disorder
Differential Diagnosis of Dizziness
Vertigo is the most common cause of dizziness. Vertigo may arise from diseases of the inner ear (peripheral) or diseases of the brainstem (central). About 90% of patients with vertigo have a peripheral etiology.
Benign paroxysmal positional vertigo (BPPV)
Labyrinthitis or vestibular neuritis
Uncommon etiologies: head trauma, herpes zoster
Cerebellar or brainstem stroke
Vertebral artery dissection
Multiple sclerosis (MS)