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CHIEF COMPLAINT

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PATIENT Image not available.

Mr. J is a 32-year-old man who comes to your office complaining of dizziness.

Image not available. What is the differential diagnosis of dizziness? How would you frame the differential?

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CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

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The differential diagnosis for dizziness is extensive, encompassing diseases of the inner ear, central and peripheral nervous system, cardiovascular system and psychiatric disease. Fortunately, an organized approach greatly simplifies evaluating the dizzy patient. The first step recognizes that most patients who complain of dizziness are actually complaining of 1 of 4 distinct symptoms: vertigo, near syncope, disequilibrium, and ill-defined lightheadedness. Each of these symptoms has its own particular differential diagnosis and evaluation.

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The first pivotal step in evaluating the dizzy patient is to clarify which symptom the patient is experiencing, since this limits the differential diagnosis and focuses the evaluation on the appropriate set of diagnostic possibilities for that particular symptom. Therefore, the first and most important pivotal 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 (Figure 14-1). Commonly used descriptions, their precipitants, and differential diagnosis are listed in Table 14-1.

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Table Graphic Jump Location
Table 14-1.Classification and characteristics of dizziness.
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Figure 14-1.

Step 1: Approach to the patient with dizziness.

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In practice, many patients often have difficulty describing their symptom and have ill-defined lightheadedness. Therefore, the ...

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