1 Taking the History of the Vertiginous Patient

This chapter gives an overview of what questions are to be asked during the history to assist in making the overall diagnosis. A physician who can master the three most common vestibular diagnoses—benign paroxysmal positional vertigo, vestibular neuronitis (labyrinthitis), and Meniere disease—can manage 80% of all vestibular complaints.1,2,3,4

Taking the time to establish a full and accurate history is the most important diagnostic endeavor in medicine. The diagnosis of a patient with vertigo or dizziness can almost always be ascertained 80% of the time by taking an accurate history without exception.^5,6 As a history is taken from a patient with complaints of vertigo, it is important to understand the various pathophysiologic and disease entities that may cause the complaint. Careful questioning about the patient’s symptoms, their duration, triggering events, and what, if anything, makes them better or worse, plays an important role in defining a possible etiology for the patient’s complaint and allows the physician to arrive at a provisional diagnosis to better direct the patient’s care.

The etiology of true vertigo can be either central or peripheral. The history may well elucidate various factors that may affect the peripheral or central systems, such as congenital abnormalities, drugs, trauma, toxins, or infections. However, other etiologies may cause patients to think they are having vertigo when other systems, such as cardiac, metabolic, or neurologic systems, are truly the root cause. Once a history is taken, the physical examination can then assist and confirm the validity of one’s suspicions about the etiology of the complaint. After the physical examination, various tests can be ordered to help pinpoint the diagnosis.

History

Intake forms are utilized by many physicians and can assist in the history taking. The information on an intake form can lead the physician to follow-up questions and to arrive at a differential diagnosis relatively quickly and efficiently.^1,5 However, I tend not to use intake forms; instead, I gain more useful information from actually letting the patient describe the condition to me. The patient’s description of what the patient experiences or is experiencing is paramount in my assessment. It is important to ascertain what the patient actually means by “dizziness.” For some patients, dizziness actually means rotation—either the world is spinning or moving around them or they are spinning around in the world. Dizziness is in essence what we call true vertigo, and it is more typical of a peripheral disorder, although central disorders cannot be completely eliminated. The patient who complains more of just lightheadedness or that they “just don’t feel quite right,” is probably not describing a vestibular disorder per se, but may be suffering from a systemic disorder, such as poor circulation, arrhythmia, neurogenic disorder, anemia, thyroid disorder, orthostatic tachycardia syndrome, or other cardiac problem. Patients who have a complaint of disequilibrium, i.e., their balance is off, are more likely to have a peripheral weakness or a central disorder, such as a cerebellar lesion, unilateral vestibular weakness, mal de barquement syndrome, or fistula.⁶ These disorders are all discussed in detail in this book.

If the patient describes true vertigo, one needs to know if the vertigo is episodic, the duration of the spell, the number of times it has occurred, and if there are any triggering events, such as a high-salt diet, allergies, movement, turning, recent upper respiratory tract infection, stress, headaches, loud noises, barotrauma, or other trauma. This information is important because it can help frame the types of diagnoses one must consider.

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