Dizziness and Vertigo (Case 57)

Dizziness and Vertigo (Case 57)

Lana Zhovtis Ryerson MD and Stephen Krieger MD

Case: A 34-year-old woman presents to the ED with dizziness. She states that 2 days ago she began to feel a “spinning sensation” and was walking around “as though she were drunk.” These symptoms worsened the day before admission, when she developed nausea and vomiting and had increasing difficulty walking. She has no significant past medical history. On exam she has beating nystagmus in all directions of gaze, worse when looking to the right. She has a slightly flattened right nasolabial fold. She has full strength and an intact sensory exam, but on coordination testing she has significant postural instability, as well as dysmetria in the right arm. She is unable to tandem walk, falling to the side.

Differential Diagnosis



Benign paroxysmal positional vertigo (BPPV)

Orthostatic hypotension

Acute labyrinthitis/vestibular neuritis

Cardiac arrhythmia

Meniere disease

Vasovagal disorder

Cerebellar infarction or hemorrhage

Intoxication/medication side effects

Perilymphatic fistula



Speaking Intelligently



Clinical Thinking

• The first step in evaluating a patient with dizziness is to take a detailed history focusing on the meaning of the term “dizziness” to the patient and to classify his or her symptoms into vertigo as opposed to presyncopal light-headedness.

Vertigo is an illusory sensation of motion of either oneself or one’s surroundings.

Presyncope is described as a light-headed, faint feeling, as though one were about to pass out, that is usually due to transient reduction of cerebral blood flow.

• If the symptoms are suggestive of vertigo, the next question that arises is whether the history and findings on examination are consistent with a central disorder such as hemorrhage/infarction of the cerebellum or a peripheral vestibular etiology such as benign positional vertigo or vestibular neuritis.

• It is vital that physicians are able to differentiate the two pathologic localizations, since central causes of acute vertigo, such as cerebellar hemorrhage and infarction, can be life-threatening and may require immediate intervention.


When evaluating a complaint of dizziness to establish if there is frank vertigo or presyncope, questions to consider include the following:

• Is there a true sensation of movement or spinning?

• Is there a feeling of faintness and light-headedness?

• Are there vague, persistent feelings of imbalance?

• What are the associated characteristics?

Nausea/vomiting may accompany vertigo.

The sensation of warmth, diaphoresis, and visual blurring may indicate presyncope.

Palpitations, dyspnea, or chest discomfort can indicate a cardiac cause.

• What is the duration of the episodes, and what are any exacerbating factors (e.g., head movement)?

• Has syncope ever occurred during an episode?

• Do episodes occur only when the patient is upright, or do they occur in other positions?

Physical Examination

• If presyncope is suspected, the physical exam should include evaluation of heart rate and blood pressure in the supine, sitting, and standing positions to evaluate for orthostatic hypotension. Assessment of the pulse and direct cardiac auscultation may assist in determining if the episode is associated with arrhythmia.

• When vertigo is suspected, the clinical exam, with particular attention to nystagmus, helps to distinguish between peripheral and central vestibular etiologies.

Feature of Nystagmus

Peripheral (Labyrinth or Nerve)

Central (Brainstem or Cerebellum)

Latency of nystagmus

3–40 sec

None: immediate vertigo and nystagmus

Fatigability of nystagmus



Direction of nystagmus

Unidirectional, often rotatory

Can be bidirectional, unidirectional, or vertical

Visual fixation

Inhibits nystagmus and vertigo

No inhibition

Intensity of vertigo



Tinnitus and/or hearing loss

Often present

Usually absent

Associated CNS abnormalities


Extremely common (e.g., diplopia, hiccups, cranial neuropathies, dysarthria)

Common causes

BPPV, vestibular neuritis, labyrinthitis, Meniere disease

Infarction, hemorrhage, multiple sclerosis, neoplasm


Figure 65-1 The Dix-Hallpike maneuver. With the patient sitting on the exam table (facing forward and eyes open), the physician turns the patient’s head 45 degrees to the right (A). The physician then supports the patient’s head as the patient lies back quickly from a sitting to a supine position, ending with the head hanging 30 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). Next the maneuver is repeated with the patient’s head initially turned to the left. A positive test is indicated if any of these maneuvers produce vertigo with or without nystagmus.

Tests for Consideration

• If stroke or hemorrhage is suspected, laboratory studies including CBC and prothrombin time/partial thromboplastin time (PT/PTT) should be performed. Other tests that may be helpful when evaluating peripheral vertigo in the outpatient setting include electronystagmography (ENG) and audiography.

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Oct 3, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Dizziness and Vertigo (Case 57)

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