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++

Probability diagnosis

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Anxiety-hyperventilation

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Postural hypotension

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Simple faint—vasovagal

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Acute vestibulopathy (V)—viral illness

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Benign paroxysmal positional vertigo (V)

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Motion sickness (V)

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Post head injury (V)

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Cervical dysfunction/spondylosis

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Note: V = vertigo

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Serious disorders not to be missed

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Neoplasia/cancer:

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  • acoustic neuroma

  • posterior fossa tumour

  • other brain tumours, primary or secondary

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Intracerebral infection (e.g. abscess)

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Cardiovascular:

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  • arrhythmias

  • myocardial infarction

  • aortic stenosis

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Cerebrovascular:

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  • vertebrobasilar insufficiency

  • brain stem infarct (e.g. PICA thrombosis)

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Multiple sclerosis

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Pitfalls (often missed)

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Ear wax-otosclerosis

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Arrhythmias

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Hyperventilation

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Alcohol and other drugs (incl. illicit, e.g. cocaine)

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Cough or micturition syncope

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Vertiginous migraine/migrainous vertigo

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Parkinson disease

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Meniere syndrome (overdiagnosed)

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Rarities:

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  • Addison disease

  • neurosyphilis

  • autonomic neuropathy

  • hypertension

  • subclavian steal

  • perilymphatic fistula

  • Shy–Drager syndrome

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Masquerades checklist

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Depression

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Diabetes (hyper and hypoglycaemia)

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Drugs (several)

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Anaemia

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Thyroid disorder (possible)

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Spinal dysfunction

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UTI (possible)

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Is the patient trying to tell me something?

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Very likely. Consider anxiety and/or depression.

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Key history

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Careful history to determine if the problem is vertigo or pseudovertigo (giddiness, faintness or disequilibrium). Check for neurological symptoms, aural symptoms and visual symptoms. Recent history of respiratory infection or head injury. Drug history including illicit drugs and alcohol (?acute intoxication).

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Key examination

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  • General examination including gait

  • Cardiovascular, auditory and neurological examinations

  • Hallpike manoeuvre and Epley test

  • Forced hyperventilation test

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Key investigations

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  • FBE

  • b glucose

  • audiometry

  • ECG, ?Holter monitor

  • Other tests according to history and examination

  • Consider MRI, especially if acoustic neuroma or other tumour suspected

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Diagnostic tips

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  • A sudden attack of vertigo in a young person after a recent URTI suggests vestibular neuronitis.

  • Dizziness is often multifactorial, especially in the elderly.

  • Commonly prescribed drugs, especially antihypertensives, antidepressants, aspirin and salicylates, glyceryl trinitrate, benzodiazipines, major tranquilisers, antiepileptics and antibiotics, can cause dizziness.

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