What is the initial workup for a 59-year-old adult presenting with dizziness?

Initial Workup for Giddiness in a 59-Year-Old Adult

The initial workup should focus on a detailed history characterizing the timing and triggers of dizziness, followed by targeted physical examination including orthostatic vital signs, neurologic examination, Dix-Hallpike maneuver, and a 12-lead ECG, with laboratory testing and imaging reserved for specific clinical indications rather than routine use. 1, 2

History Taking: The Critical First Step

The history is more diagnostically valuable than the quality of symptoms patients describe. Focus on:

• Timing and duration: Seconds suggest benign paroxysmal positional vertigo (BPPV), minutes to hours suggest vestibular migraine or Meniere disease, days suggest vestibular neuritis 3, 1
• Triggers: Head position changes strongly suggest BPPV (42% of vertigo cases in non-specialty settings) 3
• Associated symptoms: Hearing loss, tinnitus, or aural fullness suggest Meniere disease; headache with photophobia/phonophobia suggests vestibular migraine 3
• Cardiovascular risk factors: At age 59, assess for hypertension, diabetes, hyperlipidemia, heart failure, and atrial fibrillation as these increase risk of central causes 4, 5

Physical Examination: Structured and Targeted

Essential Components:

• Orthostatic vital signs: Measure blood pressure and heart rate supine and after 3 minutes of standing; positive if systolic BP drops ≥20 mmHg or diastolic BP drops ≥10 mmHg 4, 1
• Cardiovascular examination: Auscultate for murmurs suggesting aortic stenosis or structural heart disease 4
• Neurologic examination: Assess for focal deficits, dysarthria, dysmetria, dysphagia, or sensory/motor loss that suggest posterior circulation stroke 3

Specialized Vestibular Testing:

• Dix-Hallpike maneuver: Perform if episodic vertigo triggered by head movements; positive test shows rotatory nystagmus lasting <1 minute 3, 1
• Nystagmus assessment: Down-beating nystagmus, direction-changing nystagmus without head position change, or baseline nystagmus without provocation suggest central (not peripheral) causes 3

Critical pitfall: Patients with acute persistent vertigo and normal neurologic examination may still have posterior circulation stroke in 11-25% of cases 3. The HINTS examination (head-impulse, nystagmus, test of skew) can help distinguish peripheral from central causes in acute vestibular syndrome 1, 2.

Diagnostic Testing: Selective, Not Routine

Electrocardiogram:

• 12-lead ECG is essential to evaluate for arrhythmias, conduction abnormalities (including AV blocks that can cause presyncope), or ischemia 4, 5

Laboratory Testing:

Order based on clinical suspicion, not routinely 1, 6:

• Complete blood count: If anemia suspected 4
• Glucose: To rule out hypoglycemia, especially in diabetics 4
• Electrolytes: If dehydration, vomiting, or medication effects suspected 5
• Renal function: Impaired renal function predicts recurrent syncope 4
• Thyroid function: Only if clinical suspicion for thyroid dysfunction 5

Important caveat: Laboratory testing plays a limited role in most dizziness evaluations and should not be ordered routinely 1, 6.

Imaging: Usually Not Required Initially

Imaging is NOT indicated for typical BPPV with positive Dix-Hallpike testing 3. Consider imaging only when:

• Atypical features present: Negative or atypical Dix-Hallpike testing, lack of response to repositioning maneuvers, or short-term symptom recurrence 3
• Central causes suspected: Focal neurologic deficits, severe headache, or high vascular risk 3
• MRI brain with and without IV contrast is preferred over CT when imaging is indicated, as it provides superior soft tissue resolution and detects inflammatory, infectious, demyelinating, or mass lesions 3

Critical point: In emergency department studies, CT imaging for dizziness with normal neurologic examination detects contributory CNS pathology in <1% of cases 3.

Common Diagnostic Pitfalls to Avoid

• Missing medication-induced orthostatic hypotension: Review all medications, particularly antihypertensives, diuretics, and psychotropics 4
• Failing to distinguish syncope from vertigo: Syncope has rapid recovery without postictal state, unlike seizures 4
• Overlooking vertebrobasilar insufficiency: Isolated vertigo attacks lasting <30 minutes without hearing loss may precede stroke by weeks or months; look for gaze-evoked nystagmus and additional neurologic signs 3
• Misdiagnosing vestibular migraine as BPPV: Vestibular migraine requires migraine history and associated migrainous features during ≥50% of dizzy episodes 3

Age-Specific Considerations for 59-Year-Olds

At age 59, this patient has increased risk for:

• Stroke and tumors: Incidence increases with age 3
• Falls: One-third of adults >65 years fall annually; BPPV increases fall risk 12-fold 3
• Cardiovascular causes: Male sex and advancing age are higher-risk features for cardiac syncope 4