Dizziness : History and Examination



Mnemonic: 4D-3E-2Fg-2H

1. Define “Dizziness”:

  • Room is spinning/rocking/somersaulting – Vertigo
  • Feel like “going to faint” – Near-syncope
  • “Going to fall” or “Unsteady on feet” – Disequilibrium
  • Feel like they’ve or are “left their body” or “floating/swimming” – Psychophysiologic dizziness

2. Duration of each episode:

  • Seconds: BPPV
  • Minutes: TIA or Vertebro-basilar insufficiency
  • Hours: Meniere’s disease and Migraines
  • Continuous for days: Labyrinthitis, Vestibular neuronitis

3. Diplopia, Dysarthria, Dysphagia, Gait abnormalities or orther focal neurologic complaints – Central cause of vertigo

4. Dysrhythmia symptoms – Chest pain, Shortness of breath or Palpitations

5. Exacerbation:

  • With head turning, lying down, or rolling over in bed – vertigo
    • Change in head position – BPPV
    • Loud sounds – “Tulio phenomenon” (Perilymph fistula or Meniere’s disease)
  • With standing from sitting/reclining position – orthostatic hypotension
  • Walking or standing compared with sitting or lying – disequilibrium
  • Stress – psychogenic vertigo

6. Eyes:

  • Vertigo that decreases with visual fixation (more with eyes closed) – vestibular (peripheral) origin
  • Vertigo that doesn’t lessen with visual fixation (same with eyes open or closed) – central origin

7. Ears:

  • Hearing loss: Cerumen impaction, Otitis media, Cerebello-pontine angle tumors
  • Tinnitus: Meniere’s disease, Acoustic neuroma, Medication toxicity

6. Febrile viral illness: Recent viral illness – Labyrinthitis or Vestibular neuronitis

7. Food association: Caffeine and lactate may precipitate panic attacks

8. Head trauma in past: BPPV

9. Headache: Migraine or Vertebro-basilar insufficiency


Eyes for Nystagmus

Vestibular origin:

  • Fast component – beats towards the side of lesion
  • Inhibited by visual fixation
  • Direction of nystagmus doesn’t change with the direction of gaze
  • Nystagmus is fatiguable

Central origin:

  • Nystagmus is not inhibited by visual fixation
  • Nystagmus changes direction with the change in direction of gaze
  • Nystagmus is not fatiguable


  1. External auditory canal: vesicles (Ramsay-hunt syndrome), cerumen, cholesteatoma
  2. Tympanic membrane: signs of otitis media
  3. Hearing: unilateral hearing loss in labyrinthitis, cerumen impaction, meniere’s disease or acoustic neuroma

Neurologic Examination

  1. Cranial nerves
  2. Cerebellar signs
  3. Romberg’s sign:
    • Sensory ataxia: Patient loses balance when eyes are closed (removal of visual compensation)
    • Cerebellar ataxia: Patient loses balance on standing regardless of eyes being open or closed
  4. Gait

Clinical Tests

1. Orthostatic hypotension: fall in systolic blood pressure of at least 15–20mmHg within 2 minutes of standing upright.

2. Hallpike test

3. Head thrust/impulse test: The patient’s head is quickly rotated about 15° to the side while the patient fixates on the examiner’s nose. With unilateral peripheral vestibular loss (like labyrinthitis or vestibular neuritis), the eyes cannot maintain focus, and a saccade (quick rotation of the eyes from one fixation point to another) will occur bringing the eyes back to the examiner’s nose.

4. Hennebert’s test: Reproduction of symptoms on pneumatic otoscopy

  • True positive – perilymphatic fistula
  • False positive – meniere’s disease and otosyphilis

Other examinations must not be missed:

  1. Vital signs
  2. Cardiovascular examination

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