Clinical Pearl Wednesday #7

Have a patient complaining of dizziness? First ask them to describe how the dizziness feels. If it is a spinning or a pulling sensation, then it is likely a benign finding. Patients will often describe the sensation as being pulled to the wall or the floor. Ask them if this is how it feels.

Your next job is to determine if the vertigo is peripheral or central in origin. Central vertigo means it is coming from the central nervous system or the brain. This could include a stroke or a brain tumor for example. Peripheral vertigo means it is likely coming from the ears. This could be from fluid levels behind the tympanic membrane or an acute inflammatory condition for example.

To determine the origin, you need to ask the patient if the dizziness can be reproduced. Often times they will report that it is exacerbated by moving their head to fast, laying down, or looking to the sides. This intermittent dizziness is peripheral in nature. If the dizziness is a constant sensation that cannot be reproduced, begin thinking central vertigo!

On physical exam, peripheral vertigo will show lateral nystagmus where as central vertigo will show vertical nystagmus. You can exacerbate the dizziness in peripheral vertigo by utilizing the Dix-Hallpike maneuver and the Head Impulse Test. YouTube these!

The neurological exam with peripheral vertigo will be normal. With central vertigo though, an abnormality will usually be picked up such as a positive Romberg test, gait disturbances, or coordination deficits.

I diagnosed metastatic brain cancer in a 63 year old female one time complaining of dizziness. I could not reproduce it, the dizziness was constant in nature, and she could not complete a heel to toe test without stumbling. CT head revealed diffuse metastatic disease. Another time a 65 year old female could not complete a heel to toe test without stumbling, had vertical nystagmus, and the CT head revealed an acute bleed!

If it is peripheral in nature, it will usually self resolve on its own in 1-2 weeks. You can prescribe Meclizine or a short course of Prednisone. If it is central in origin, they need an emergent work up in the Emergency Department.

8 Responses

  1. Thank you for the Wednesday pearls! I look forward to them and it has certainly expanded my knowledge. Have a great day!

  2. The positional vertigo you are reporting about is BPPV -Benign Paroxysmal Positional Vertigo. Nice write up.

  3. Great information!! These are extremely helpful for a newer no problem working in urgent care. Thank you for sharing your knowledge!!

  4. I diagnosed vestibular neuritis in a 50 yo female once. She was “spinning” and very nauseated with normal eye movement and coordinated gait with assist to keep from falling. Followed all commands. Same day referral to ENT with meclizine/zofran .. no ER! ENT was quite pleased and so was I. Great feeling to know the difference, however, I think most don’t want to be sued so send to ER avoids lawsuit ?

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