A 69-Year-Old Man With Chronic Dizziness

Abstract

is a 69-year-old man troubled by dizziness. He is retired from his job as building superintendent for a public school. He is married, lives in the Boston, Mass, suburbs, and has managed Medicare insurance.Mr D dates the onset of his dizziness to 1994, when the symptoms were predominantly vertiginous. He described the sensation as "everything is moving" and "like I had too much to drink." These episodes lasted 1 to 2 hours, occurred several times per week, and often came on suddenly, such as when arising in the middle of the night. At that time, use of meclizine hydrochloride seemed to decrease the symptoms. Results of a magnetic resonance imaging (MRI) scan of the brain at that time were normal.The symptoms seemed to resolve over time, but in 1996, Mr D fell off a ladder from a height of 1.5 m (5 ft) and struck his head, shoulder, and back. In 1997, the symptoms of dizziness recurred, although Mr D then described a sensation of "lightheadedness, as if I will faint." He complained of a fear of "missing steps" and an "inability to focus." In 1998, the dizziness became more prominent, with a sensation of "seasickness and having to hold on to the walls." The episodes lasted for hours to days, were often associated with nausea, and were not necessarily associated with change in position. The dizziness did not respond to meclizine. Mr D's medical history is notable for peptic ulcer disease, treated with hemigastrectomy and vagotomy, and complicated by pancreatic phlegmon and ultimately diabetes. He has had renal colic, decreased hearing documented by audiometry, and back pain treated with steroid injections and oral medications. He has mild essential hypertension. He quit smoking cigarettes and drinking alcohol many years ago. There is no relevant family history.His current medications include oxycodone controlled-release tablets, 40 mg twice daily; gabapentin, 300 mg 8 times daily; atenolol, 50 mg/d; glyburide, 7.5 mg twice daily; and metformin hydrochloride, 500 mg twice daily.Physical examination revealed a well-appearing man with a blood pressure of 140/80 mm Hg and a heart rate of 80/min without orthostatic changes. Findings from a funduscopic ex-amination were normal. There was cerumen in the right ear. Carotid pulses were 2+ without bruits. Neurologic examination was notable for normal cranial nerves, motor function, sensory function, and reflexes. The Bárà ny maneuver did not evoke nystagmus. Rotating him in a chair, however, did bring on a typical sense of dizziness. While he read an eye chart, his visual acuity decreased from 20/40 to 20/100 while shaking his head.Laboratory results showed normal complete blood cell count and normal electrolyte, serum urea nitrogen, creatinine, glucose, hemoglobin A 1c , vitamin B 12 , and folate levels. Mr D was recently referred to an otolaryngologist for further evaluation.

Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

“…73,74 This approach differs slightly from European practice 37 and from terminology for a planned international classification of vestibular disorders, 75 which define dizziness and vertigo separately. In keeping with current North American practice, 20 for this re view we use dizziness as an umbrella term that includes vertigo as a subset, recognizing, however, that recent data suggest drawing any linguistic distinction between dizziness and vertigo probably has little diagnostic value.…”

How Often is Dizziness from Primary Cardiovascular Disease True Vertigo? A Systematic Review

“…It is commonly encountered across medical settings 1,2 and in the general population 3 . The traditional approach to diagnosis relies heavily on the premise that dizziness type predicts the underlying etiology 4 . This "quality-of-symptoms" approach suggests that dizziness should be classified as one of four types based on the nature (quality) of dizziness: (1) vertigo (spinning or motion), (2) presyncope (impending faint), (3) disequilibrium (unsteadiness when walking), or (4) non-specific dizziness (any other dizziness sensation) 5 .…”

“…This "quality-of-symptoms" approach suggests that dizziness should be classified as one of four types based on the nature (quality) of dizziness: (1) vertigo (spinning or motion), (2) presyncope (impending faint), (3) disequilibrium (unsteadiness when walking), or (4) non-specific dizziness (any other dizziness sensation) 5 . Symptom quality then directs subsequent diagnostic inquiry, with vertigo prompting a search for vestibular causes, presyncope a search for cardiovascular causes, disequilibrium a search for neurologic causes, and non-specific dizziness a search for psychiatric or metabolic ones 4 . This represents the standard approach described in commonly used medical texts 6 and published medical literature 3 .…”

Radiology in Vertigo and Dizziness

“…Peripheral causes [2][3][4][5][6][7][8] • Acute labyrinthitis The appropriate imaging modality depends upon the associated symptoms and is guided by ACR criterion as given in Table 1 (ACR Appropriateness Criteria)**.…”

“…1 Physicians should consider neuroimaging studies in patients with vertigo who have neurologic signs and symptoms, risk factors for cerebrovascular disease or progressive unilateral hearing loss. 2 …”