What is the initial workup for a patient presenting with dizziness in the hospital?

Initial Workup for Dizziness in the Hospital

The initial workup for a patient presenting with dizziness should focus on timing and triggers rather than symptom quality, including a targeted history, physical examination with orthostatic blood pressure measurements, neurological assessment, and a 12-lead ECG. 1

Step 1: Targeted History

Focus on these key elements:

• Timing of symptoms:

  • Episodic vs. continuous
  • Duration of episodes (seconds, minutes, hours, days)
  • Onset (sudden vs. gradual)

• Triggers:

  • Positional changes (suggestive of BPPV)
  • Standing up (suggestive of orthostatic hypotension)
  • Head movements
  • Specific activities

• Associated symptoms:

  • Hearing loss, tinnitus, aural fullness (suggestive of Ménière's disease)
  • Headache, photophobia (suggestive of vestibular migraine)
  • Neurological symptoms (suggestive of stroke/TIA)
  • Visual disturbances

• Medication review:

  • Antihypertensives
  • Cardiovascular medications
  • Other medications with dizziness as side effect

Step 2: Physical Examination

• Vital signs:

  • Orthostatic blood pressure measurements (lying, sitting, standing)
  • Heart rate and rhythm

• Neurological examination:

  • Cranial nerve assessment
  • Motor and sensory function
  • Coordination tests
  • Gait assessment

• Vestibular examination:

  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - critical for differentiating peripheral from central causes 1, 2
  • Dix-Hallpike maneuver - for suspected BPPV 1, 2
  • Assessment for spontaneous nystagmus

• Cardiovascular examination:

  • Heart sounds
  • Carotid bruits

Step 3: Initial Diagnostic Testing

• 12-lead ECG - to evaluate for cardiac causes 1

• Laboratory tests (based on clinical suspicion, not routinely):

  • Complete blood count
  • Electrolytes
  • Blood glucose
  • Renal function tests

• Imaging (when indicated):

  • MRI brain (without contrast) is recommended for:
    • Acute Vestibular Syndrome with abnormal HINTS examination
    • Presence of neurological deficits
    • High vascular risk patients
    • Chronic undiagnosed dizziness not responding to treatment 1

Differential Diagnosis Framework

Categorize dizziness based on clinical presentation:

1. Vertigo (spinning sensation):

   • Peripheral causes: BPPV, Ménière's disease, vestibular neuritis, labyrinthitis
   • Central causes: Stroke, vertebrobasilar insufficiency, multiple sclerosis

2. Presyncope (feeling of impending faint):

   • Orthostatic hypotension
   • Cardiac arrhythmias
   • Medication effects

3. Disequilibrium (unsteadiness):

   • Neurological disorders (Parkinson's disease)
   • Peripheral neuropathy
   • Cerebellar disorders

4. Non-specific lightheadedness:

   • Psychiatric disorders (anxiety, depression)
   • Hyperventilation
   • Metabolic disorders

Important Clinical Pearls

• Vertebrobasilar insufficiency is a critical condition to exclude, as isolated transient vertigo may precede stroke by weeks or months 1

• The HINTS test has superior sensitivity to MRI in the first 48 hours for detecting stroke in patients with acute vestibular syndrome 1, 3

• BPPV is the most common cause of vertigo in elderly patients but should be a diagnosis of exclusion after ruling out more serious conditions 1, 2

• Medication side effects are common causes of dizziness, particularly in elderly patients 1

• A final diagnosis is not obtained in approximately 20% of dizziness cases 4

• The five most frequent categories of dizziness are vasovagal syncope/orthostatic hypotension (22.3%), vestibular causes (19.9%), fluid and electrolyte disorders (17.5%), circulatory/pulmonary causes (14.8%), and central vascular causes (6.4%) 3

By following this systematic approach, clinicians can efficiently evaluate patients with dizziness and identify potentially life-threatening conditions requiring urgent intervention.