Standardizing your approach to dizziness and vertigo

Abnormal gait may indicate peripheral neuropathy, while a positive Romberg’s test suggests involvement of the proprioceptive receptors and/or their pathway.

Up to 15% of cases of benign paroxysmal positional vertigo may result from previous head injury.

Central/peripheral vestibular causes. The head impulse, nystagmus, test of skew (HINTS) examination can differentiate between central and peripheral vestibular causes of dizziness and rule out stroke (a central vestibular cause).²² (See https://collections.lib.utah.edu/details?id=177180 for a video demonstrating the steps involved in performing the HINTS examination.) The head impulse (HI) portion of the exam is performed by moving the patient’s head side to side, while having the patient focus on the examiner’s nose. Rapid movements of both eyes (“abnormal” HI) suggest a peripheral etiology, while no eye movement with gaze fixated on the examiner’s nose (“normal” HI) is concerning for stroke or another central cause of vertigo.²²

Nystagmus is assessed by having the patient follow the examiner’s finger as it moves in a horizontal direction. Spontaneous horizontal unidirectional nystagmus suggests a peripheral cause, while vertical or torsional bidirectional (direction-changing) nystagmus points to a central cause.²²

The test of skew is executed by covering and uncovering each of the patient’s eyes, while asking the patient to look ahead. Vertical deviation of the eye after uncovering suggests a central etiology, more specifically one involving the brainstem.²²

Diagnostic testing/imaging has a limited, but pivotal role

There is a limited role for routine laboratory testing in patients with dizziness. However, for those patients with underlying medical conditions (eg, diabetes), which may contribute to the symptoms, routine blood work can be ordered (ie, finger-stick blood glucose test).²²

Continue to: More worrisome suspicions