What is the best course of action for a female patient in her late 60s with nausea and dizziness, and a normal electrocardiogram (EKG)?

Evaluation and Management of Nausea and Dizziness with Normal EKG in a Late 60s Female

Despite the normal EKG, this patient requires urgent evaluation for acute vestibular syndrome versus posterior circulation stroke, as the combination of nausea and dizziness in this age group carries significant risk for life-threatening central causes that may not manifest on EKG. 1, 2

Immediate Risk Stratification

The normal EKG is reassuring but does not exclude serious pathology. The ACC/AHA explicitly classifies dizziness as a Class I indication for EKG, and while this patient has completed that step, the normal result shifts focus to neurologic and vestibular causes rather than providing definitive reassurance. 1

Critical Next Steps Based on Timing and Triggers

The diagnostic approach must categorize this patient using the "timing and triggers" paradigm rather than outdated symptom quality classification:

• If symptoms are continuous and ongoing (Acute Vestibular Syndrome): This represents the highest-risk scenario requiring immediate differentiation between peripheral vestibular neuritis and posterior circulation stroke using the HINTS examination (head-impulse, nystagmus, test of skew). 2, 3

• If symptoms are episodic and spontaneous (Spontaneous Episodic Vestibular Syndrome): Associated symptoms help differentiate vestibular migraine from transient ischemic attack. In a woman in her late 60s, TIA must be strongly considered. 2, 3

• If symptoms are triggered by position changes (Triggered Episodic Vestibular Syndrome): Perform Dix-Hallpike maneuver to differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. 2, 3

Essential Physical Examination Components

Perform these specific maneuvers immediately:

• Orthostatic vital signs: Measure blood pressure and heart rate supine and after 3 minutes standing to assess for orthostatic hypotension, which is common in elderly patients and may be medication-related. 1, 4

• HINTS examination (if acute vestibular syndrome): This bedside examination is more sensitive than early MRI for posterior circulation stroke and includes head impulse test, assessment of nystagmus pattern, and test of skew deviation. 2, 3

• Dix-Hallpike maneuver (if triggered symptoms): Essential for diagnosing BPPV, the most common peripheral vestibular disorder. 4, 2

• Full neurologic examination: Assess for focal deficits, cerebellar signs, and cranial nerve abnormalities that suggest central pathology. 4, 5

Cardiac Considerations Despite Normal EKG

While the normal EKG reduces concern for acute cardiac causes, several cardiac issues remain possible:

• Arrhythmias may be intermittent: The single normal EKG does not exclude paroxysmal arrhythmias. If cardiac symptoms persist or recur, ambulatory ECG monitoring (24-48 hour Holter or event recorder) is indicated. 6, 1

• Structural heart disease: If the history or physical examination suggests structural abnormalities (exertional symptoms, murmurs, signs of heart failure), echocardiography should be performed despite the normal EKG. 1

• Medication review: Elderly patients often take multiple cardiovascular medications (antihypertensives, diuretics, antiarrhythmics) that can cause dizziness and nausea through orthostatic hypotension or other mechanisms. 6, 4

High-Risk Features Requiring Urgent Neuroimaging

Obtain urgent CT or MRI if any of these are present:

• Age over 60 years with new-onset dizziness (this patient qualifies by age alone for heightened concern). 6, 2

• Associated headache, focal neurologic deficits, or altered mental status. 2, 5

• Inability to ambulate due to severe imbalance. 2, 3

• Abnormal HINTS examination suggesting central pathology (normal head impulse test, direction-changing nystagmus, or skew deviation). 2, 3

• Cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) increase stroke risk. 2, 5

Management Algorithm

For peripheral vestibular causes (after excluding central pathology):

• BPPV: Canalith repositioning procedures (Epley maneuver) are first-line treatment with high success rates. 4

• Vestibular neuritis: Vestibular rehabilitation is the primary treatment; short-term vestibular suppressants (meclizine, dimenhydrinate) may provide symptomatic relief but should be limited to 2-3 days to avoid delaying central compensation. 4, 7

For nausea management:

• Antiemetics (ondansetron, metoclopramide) can be used for symptomatic relief, but identifying and treating the underlying cause is paramount. 7

• Avoid prolonged use of vestibular suppressants as they impair central nervous system compensation for vestibular disorders. 4

Critical Pitfalls to Avoid

• Do not rely on symptom quality alone: The traditional approach of categorizing dizziness as "vertigo," "presyncope," or "disequilibrium" does not distinguish benign from dangerous causes and leads to frequent misdiagnosis. 2, 5, 3

• Do not assume normal EKG excludes all cardiac causes: Intermittent arrhythmias and structural heart disease may not manifest on a single resting EKG. 6, 1

• Do not miss posterior circulation stroke: In patients over 60 with acute vestibular syndrome, stroke risk is substantial and requires HINTS examination or neuroimaging. 2, 3

• Do not overlook medication-induced causes: Review all medications, particularly antihypertensives, diuretics, and psychotropic agents that commonly cause dizziness in elderly patients. 6, 4