What is the approach to diagnosing a patient (Pt) working at heights with a history (hx) of dizziness?

From the Guidelines

For a patient working at heights with a history of dizziness, a thorough diagnostic evaluation is crucial, starting with a detailed history and physical examination, including the Dix-Hallpike maneuver to assess for benign paroxysmal positional vertigo (BPPV), as recommended by the 2017 clinical practice guideline update 1. When approaching the diagnosis, it's essential to consider the patient's safety and the potential risks associated with working at heights. The diagnostic process should involve:

• A comprehensive history focusing on the characteristics of dizziness, timing, triggers, associated symptoms, and medication review
• A thorough physical examination, including vital signs, orthostatic measurements, cardiovascular assessment, neurological examination with cerebellar testing, and vestibular evaluation
• The Dix-Hallpike maneuver should be performed to diagnose posterior semicircular canal BPPV, as stated in the guideline 1
• If the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, a supine roll test should be performed to assess for lateral semicircular canal BPPV, as recommended in the guideline 1
• Laboratory testing and specialized testing, such as electrocardiogram, Holter monitoring, echocardiography, audiometry, and vestibular function tests, should be considered based on the patient's symptoms and physical examination findings
• Brain imaging (MRI or CT) should be considered if neurological causes are suspected While investigating, the patient should be temporarily restricted from working at heights for safety. Management depends on the underlying cause, and occupational considerations are paramount. Return to work at heights should only be permitted once the condition is adequately diagnosed and controlled, potentially with workplace accommodations or job modification if dizziness cannot be completely resolved. The clinician should differentiate BPPV from other causes of imbalance, dizziness, and vertigo, and assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling, as stated in the guideline 1.

From the FDA Drug Label

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From the Research

Approach to Diagnosing Dizziness

The approach to diagnosing a patient with a history of dizziness, particularly one working at heights, involves a comprehensive evaluation of the patient's symptoms, medical history, and physical examination. The following steps can be taken:

• Focus on the timing of the events and triggers of dizziness to develop a differential diagnosis 2
• Perform a physical examination, including:
  • Orthostatic blood pressure measurement
  • Full cardiac and neurologic examination
  • Assessment for nystagmus
  • Dix-Hallpike maneuver (for patients with triggered dizziness)
  • HINTS (head-impulse, nystagmus, test of skew) examination when indicated 2
• Use tools such as dizziness questionnaires and targeted history taking to elicit information from the patient 3
• Consider laboratory testing and imaging if necessary, although they are usually not required 2

Differential Diagnosis

The differential diagnosis for dizziness is broad and includes peripheral and central causes 2. Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent 2. The diagnosis of hemodynamic orthostatic dizziness/vertigo requires specific criteria, including episodes of dizziness triggered by arising or present during upright position, orthostatic hypotension or postural tachycardia syndrome, and no better account by another disease or disorder 4.

Treatment

Treatment for dizziness depends on the etiology of the symptoms 2. Vestibular rehabilitation is helpful in treating many peripheral and central etiologies 5, and canalith repositioning procedures (e.g., Epley maneuver) are effective in treating benign paroxysmal positional vertigo 2. Other etiologies of dizziness require specific treatment to address the cause 2.