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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):

  1. Vertigo

  2. Near syncope

  3. Dysequilibrium

  4. Nonspecific dizziness

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.

Table 13–1. Classification and Characteristics of Dizziness.

Differential Diagnosis of Dizziness

  1. 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.

    1. Peripheral

      1. Benign paroxysmal positional vertigo (BPPV)

      1. Labyrinthitis or vestibular neuritis

      1. Meniere disease

      1. Uncommon etiologies: head trauma, herpes zoster

    1. Central

      1. Cerebrovascular disease

        1. Vertebrobasilar insufficiency

        1. Cerebellar or brainstem stroke

        1. Cerebellar hemorrhage

        1. Vertebral artery dissection

      1. Cerebellar degeneration

      1. Migraine

      1. Multiple sclerosis (MS)

      1. Alcohol ...

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