From the Guidelines
The appropriate workup for a patient presenting with dizziness should begin with a thorough history and physical examination to distinguish between vertigo, presyncope, disequilibrium, and lightheadedness, as recommended by the 2020 clinical practice guideline for Ménière's disease 1. Key history elements include:
- Onset and duration of symptoms
- Triggers and associated symptoms
- Medication review The physical examination should include:
- Vital signs
- Orthostatic measurements
- Neurological assessment
- Specialized tests like the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV) and the head impulse test for vestibular dysfunction, as outlined in the 2017 clinical practice guideline for BPPV 1. Laboratory tests should include:
- Complete blood count
- Basic metabolic panel
- Thyroid function tests to rule out anemia, electrolyte abnormalities, and thyroid disorders
- Electrocardiogram to identify cardiac arrhythmias, especially in patients with presyncope For persistent or concerning symptoms, advanced imaging such as CT or MRI of the brain may be necessary to rule out stroke, tumors, or other structural abnormalities, as suggested by the 2020 guideline for Ménière's disease 1. Audiometry and vestibular testing may be indicated for patients with hearing loss or persistent vertigo, but vestibular function testing and electrocochleography (ECochG) should not be routinely used to establish the diagnosis of Ménière's disease, as stated in the 2020 guideline 1. Referral to specialists like neurology, otolaryngology, or cardiology should be considered based on the suspected etiology. This systematic approach helps identify the underlying cause of dizziness, which is essential for appropriate management, as treatment varies significantly depending on whether the cause is peripheral vestibular, central nervous system, cardiovascular, or metabolic in nature.
From the Research
Appropriate Workup for Dizziness
The workup for a patient presenting with dizziness involves a combination of history, physical examination, and laboratory investigations.
- The history is crucial in identifying the underlying cause of dizziness, with studies showing that it leads to the final diagnosis in a significant proportion of cases 2.
- The physical examination also plays a vital role, particularly in detecting cardiovascular causes of dizziness, such as valvular heart disease, heart failure, and atrial fibrillation 3.
- Laboratory investigations, including electrocardiogram (ECG) and troponin measurement, may be necessary to rule out acute coronary syndrome (ACS) or other cardiac conditions 4.
- The choice of laboratory investigations depends on the patient's presentation and medical history, with some studies suggesting that technological aids to diagnosis, such as ambulatory ECG monitoring, may be useful in detecting arrhythmias and other cardiac conditions 5.
Key Components of the Workup
- A thorough medical history to identify potential causes of dizziness and associated symptoms
- A physical examination to detect signs of cardiovascular or other systemic diseases
- Laboratory investigations, such as ECG and troponin measurement, to rule out ACS or other cardiac conditions
- Consideration of technological aids to diagnosis, such as ambulatory ECG monitoring, in certain cases
Considerations in the Workup
- The importance of considering alternative causes of dizziness, rather than relying solely on the patient's presentation 4
- The need for further research into the value of physical examination and laboratory investigations in the workup of dizziness, particularly in low-resource settings 3
- The potential benefits and limitations of technological aids to diagnosis, such as ambulatory ECG monitoring, in the workup of dizziness 5