Key Clinical Questions
How do you determine whether a hospitalized patient has a benign cause of vertigo?
How might the physical examination confirm your suspicion of a benign cause of vertigo?
How do you treat vertigo?
Dizziness and vertigo are common complaints and encompass a myriad of symptoms that may stem from many organ systems. A sensation of lightheadedness or faintness may relate to the presence of orthostatic hypotension, abnormalities of the cardiovascular system, altered ambulation as seen in patients with impaired vision and sensation of feet (multiple-sensory-defect dizziness), or imbalance experienced by older patients (benign disequilibrium of aging). Many patients describe dizziness in reference to impaired ambulation and fear of falling or when they have blurred vision or feel confused. Hyperventilation may also cause symptoms of dizziness. These symptoms may be associated with significant disability and possibly mortality.
A sensation of lightheadedness or faintness may relate to the presence of orthostatic hypotension, abnormalities of the cardiovascular system, hyperventilation, altered ambulation as seen in patients with impaired vision and sensation of feet (multiple-sensory-defect dizziness), or imbalance commonly experienced by older patients (benign disequilibrium of aging).
A sensation of vertigo, which is defined as an illusion of movement of self or surroundings, is much more likely to be a reflection of an abnormality of the peripheral or central vestibular system. It may be physiologic, that is, occurring with seasickness or after spinning or pathologic of central or peripheral vestibular origin. The misuse of the term vertigo as a diagnostic term rather than as a symptom should be eschewed in favor of a recognized diagnostic entity. Simply assigning a diagnosis of vertigo could prematurely terminate the evaluation and thereby miss an opportunity for accurate diagnosis followed by appropriate treatment. In some cases, the term vertigo is used as shorthand for benign paroxysmal positional vertigo. Because of the high prevalence of this disorder in the outpatient setting, these patients may receive proper treatment despite sloppy documentation and failure to convey accurate information to colleagues.
This chapter primarily focuses on the symptom of vertigo in patients admitted to the hospital. Chapter 101 includes cardiac causes of presyncope. Other medical illnesses, drug toxicity, and substance abuse that may produce symptoms of dizziness and vertigo are covered elsewhere in this book. The published studies reviewing a systematic approach to the diagnosis and treatment of the symptom of vertigo relate to the outpatient or emergency room settings. Hospitalized patients are a different population. If symptoms of dizziness and vertigo are new experiences, the clinician should consider iatrogenic causes in addition to the usual suspects.
A 75-year-old woman with diabetes and hypertension underwent a total knee replacement. On the first postoperative day, she experienced vertigo when turning in her hospital bed. Each brief vertiginous episode was associated with mild nausea. The patient was essentially asymptomatic when sitting or lying still. She ...