Approach to dizziness

Dizziness is a common exam topic and a common GP presentation. We often have a laugh at the emergency department when an elderly Greek woman presents with dizziness. It is probably that we know that we will never make the dizziness go away. Many causes of dizziness are benign, however, some of them are serious and can be potentially fatal if missed.

Dizziness means different thing to different people. It is important to clarify what they actually mean by dizziness.

As per usual, John Murtagh attempts to simplify the diagnostic process:

Murtagh's diagnostic model 

Probability diagnosis 

1. - Anxiety-hyperventilation 
2. - Postural hypotension 
3. - Simple faint - vasovagal
4. - Acute vestibulopathy
5. - Benign Paroxysmal Positional Vertigo
6. - Motion sickness
7. - Post head injury
8. - Cervical dysfucntion/spondylosis 

Serious disorders not to be missed

1. Neoplasia

• Acoustic neuroma
• Posterior fossa tumour
• Other brain tumours, primary or secondary.

2. Intracerebral infection (e.g. abscess)

3. Cardiovascular 

• Arrhythmias
• Myocardial infarction 
• Aortic stenosis 

4. Cerebrovascular 

• Vertebrobasilar insufficiency 
• Brain stem infarct (e.g. PICA thrombosis)

5. Multiple sclerosis 

pitfalls (often missed)

1. Ear wax - otosclerosis
2. Arrhythmias
3. Hyperventilation 
4. ETOH and other drugs
5. Cough or micturition syncope
6. Vertiginous migraine/migrainous vertigo
7. Parkinson's disease 
8. Meniere syndrome (overdiagnosed) 
9. Ramsay-Hunt syndrome 
10. Rarities
• Addison disease
• Neurosyphilis
• Autonomic neuropath
• Hypertension 
• Subclavian steal 
• Perilymphtic fistula
• Shy-Drager syndrome 

Seven Masquerades checklists

1. Depression 

2. Diabetes

3. Drugs

4. Anaemia 

5. Thyroid disorder

6. Spinal dysfunction 

7. UTI 

Other resources about dizziness

• http://blogs.brown.edu/emergency-medicine-residency/you-make-me-dizzy-miss-lizzy-hints-for-assessing-acute-dizziness/