What workup would you recommend for a female patient presenting with dizzy spells and fatigue?

Workup for Dizzy Spells and Fatigue in a Female Patient

Initial Diagnostic Approach

The workup should prioritize a targeted history focusing on timing and triggers of dizziness, followed by specific physical examination maneuvers, with laboratory testing limited to anemia and orthostatic vital signs—imaging is only indicated if red flags are present. 1, 2, 3

History Taking: Critical Elements

The history should categorize dizziness by timing patterns rather than vague descriptors like "spinning" or "lightheadedness" 1, 2, 3:

• Brief episodic (<1 minute) triggered by head position changes → suggests BPPV 1, 2, 3
• Acute persistent (days to weeks) with constant symptoms → suggests vestibular neuritis or stroke 1, 2, 3
• Recurrent episodic (minutes to hours) with headache, photophobia, or phonophobia → suggests vestibular migraine 1, 2, 3
• Chronic (weeks to months) → consider medication effects, psychiatric causes, or posttraumatic vertigo 1, 2, 3

For the fatigue component, specifically assess 4:

• Duration and severity of fatigue (>1 month of disproportionate tiredness) 4
• Associated symptoms: palpitations, tremor, weakness, blurred vision 4
• Orthostatic symptoms: dizziness upon standing, coat-hanger pain, relief with lying down 4
• Medication review (antihypertensives, sedatives, anticonvulsants) 2, 3
• Menstrual history and pregnancy status (fatigue more marked in females <60 years) 4

Physical Examination: Essential Components

Orthostatic vital signs 4, 3:

• Measure blood pressure and heart rate supine, then at 1 and 3 minutes after standing 4
• Classical orthostatic hypotension: BP drop ≥20/10 mmHg within 3 minutes 4
• POTS: HR increase >30 bpm (or >120 bpm) within 10 minutes without orthostatic hypotension 4

Vestibular examination 1, 2, 3:

• Dix-Hallpike maneuver (gold standard for BPPV): Look for 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolving within 60 seconds 1, 2, 3
• Observe for spontaneous nystagmus patterns (central patterns are red flags) 1, 3
• Complete neurologic examination including cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin), and gait assessment 1, 3

Fall risk assessment 3:

• Ask about falls in past year, feeling unsteady, worry about falling 3
• Perform Get Up and Go test or Tinetti Balance Assessment if positive responses 3

Laboratory Testing: Selective Approach

Routine laboratory testing has extremely low yield in isolated dizziness with normal examination 1. However, given the fatigue component, targeted testing is warranted:

Essential tests 4, 1:

• Complete blood count to assess for anemia (common cause of fatigue in females) 4
• Iron studies (ferritin, iron, TIBC) even if hemoglobin normal, as low iron stores correlate with fatigue 4
• Bedside glucose (if indicated by history) 1
• Pregnancy test (in reproductive-age females) 1

Consider if clinically indicated 4:

• Inflammatory markers (ESR, CRP) if systemic symptoms present 4
• Vitamin D, magnesium levels (linked to muscle fatigue) 4
• Thyroid function tests (if other hypothyroid symptoms) 4

Imaging: Only for Red Flags

Do NOT order imaging for straightforward BPPV or isolated dizziness with normal examination 1, 2, 3. This delays treatment unnecessarily and has <1% diagnostic yield 2, 3.

MRI brain without contrast is indicated ONLY if 1, 2, 3:

• Focal neurological deficits 1, 2, 3
• Sudden unilateral hearing loss 1, 2, 3
• Inability to stand or walk 1, 2, 3
• Downbeating or other central nystagmus patterns 1, 2, 3
• New severe headache 1, 2
• Progressive neurologic symptoms 1, 2
• HINTS examination suggesting central cause (in acute vestibular syndrome) 2, 3

CT head should NOT be used instead of MRI when stroke is suspected, as it has only 20-40% sensitivity for posterior circulation infarcts 2, 3.

Critical Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke: 75-80% of posterior circulation strokes have no focal deficits 1, 2
• Do not skip the Dix-Hallpike maneuver: It is the gold standard diagnostic test for BPPV 1, 2, 3
• Do not rely on symptom quality alone ("spinning" vs "lightheadedness"): Timing and triggers are more diagnostically valuable 1, 2, 3
• Do not order comprehensive vestibular testing for straightforward BPPV: This is unnecessary and delays treatment 2
• Do not overlook medication review: This is a leading reversible cause of chronic dizziness and fatigue 2, 3
• Do not dismiss fatigue as non-specific: In females with dizziness, assess for anemia, iron deficiency, and orthostatic intolerance (POTS), which disproportionately affect young women 4

Algorithmic Summary

1. History: Categorize by timing/triggers + assess fatigue severity and orthostatic symptoms 1, 2, 3
2. Vitals: Orthostatic blood pressure and heart rate 4, 3
3. Exam: Dix-Hallpike maneuver + neurologic exam + gait assessment 1, 2, 3
4. Labs: CBC, iron studies, pregnancy test (if applicable), bedside glucose 4, 1
5. Imaging: ONLY if red flags present—use MRI, not CT 1, 2, 3
6. Treatment: If BPPV confirmed, perform Epley maneuver immediately (90-98% success rate) 1, 2, 3