What is the initial workup for a patient presenting with dizziness for 3 days?

Initial Workup for a Patient Presenting with Dizziness for 3 Days

The initial workup for dizziness should focus on determining the timing, triggers, and associated symptoms to classify the dizziness into one of four distinct vestibular syndromes, which will guide further evaluation and management. 1, 2

Step 1: Characterize the Dizziness

• Determine if the patient is experiencing true vertigo (sensation of rotation or spinning) versus non-specific dizziness (sensation of disturbed spatial orientation without false sense of motion) 1
• Classify the dizziness based on timing and triggers into one of four categories 1:
  • Acute vestibular syndrome (continuous dizziness lasting days to weeks)
  • Triggered episodic vestibular syndrome (brief episodes triggered by position changes)
  • Spontaneous episodic vestibular syndrome (recurrent episodes not triggered by position)
  • Chronic vestibular syndrome (dizziness lasting weeks to months)

Step 2: Focused History

• Duration of each episode: seconds (BPPV), minutes to hours (Ménière's, vestibular migraine), or days (vestibular neuritis, labyrinthitis) 1
• Triggers: positional changes (BPPV), pressure changes (perilymph fistula, superior canal dehiscence) 1
• Associated symptoms:
  • Hearing loss, tinnitus, or aural fullness (suggests Ménière's disease) 1
  • Headache, photophobia (suggests vestibular migraine) 1
  • Neurological symptoms like dysphasia, dysphonia, visual disturbances (suggests stroke) 1
  • Fever, otalgia (suggests infectious cause) 1
• Medication review: many medications can cause presyncope 3

Step 3: Physical Examination

• Vital signs including orthostatic blood pressure measurements 3, 4
• Complete neurological examination 4
• Otologic examination 1, 5
• Vestibular examination:
  • Nystagmus assessment (direction, duration, fatigability) 1
  • Dix-Hallpike maneuver for posterior canal BPPV 1
  • Supine roll test for lateral canal BPPV 1
  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for patients with acute vestibular syndrome to differentiate peripheral from central causes 2

Step 4: Diagnostic Testing

• Laboratory testing plays a limited role in initial evaluation but may include 3, 4:
  • Basic metabolic panel if dehydration or electrolyte abnormalities suspected
  • Complete blood count if infection suspected
  • Thyroid function tests if thyroid disorder suspected
• Imaging is generally not required in the initial workup unless 1, 2:
  • Neurological symptoms are present
  • HINTS examination suggests central pathology
  • Symptoms persist despite appropriate treatment
  • Atypical presentation or red flags are present

Common Diagnoses to Consider

• Benign Paroxysmal Positional Vertigo (BPPV): Brief vertigo (<1 minute) triggered by position changes 1
• Vestibular Neuritis: Acute prolonged vertigo without hearing loss 1
• Labyrinthitis: Acute prolonged vertigo with hearing loss 1
• Ménière's Disease: Recurrent episodes of vertigo (20 minutes to 12 hours) with fluctuating hearing loss, tinnitus, or aural fullness 1
• Vestibular Migraine: Vertigo episodes lasting minutes to hours, often with migraine history 1
• Stroke/TIA: May present with vertigo and neurological symptoms 1, 2

Red Flags Requiring Urgent Evaluation

• New-onset severe headache 2
• Focal neurological deficits 1
• Vertical or direction-changing nystagmus 2
• Abnormal HINTS examination 2
• Sudden hearing loss 1
• Inability to stand or walk 2

Common Pitfalls to Avoid

• Relying solely on the patient's description of "dizziness" without clarifying the exact nature of symptoms 1, 2
• Failing to perform the Dix-Hallpike maneuver and supine roll test in patients with positional symptoms 1
• Ordering unnecessary imaging studies for typical peripheral vestibular disorders 3, 2
• Missing central causes of vertigo by not performing a thorough neurological examination 1, 2
• Failing to recognize that approximately 20% of dizziness cases may not receive a definitive diagnosis in the initial evaluation 3