THE DIZZY PATIENT IN THE URGENT CARE SETTING AN ILLUSTRATIVE PATIENT: PRESENTATION A 61-year-old woman comes to the office complaining of dizziness. She says it began by waking her from a sound sleep on the evening after a hair appointment. When asked to describe the sensation, she says it is a feeling of violent motion, a sensation of being pulled to the right. It occurs in waves a moment after she lies down on her right side in bed. If she remains motionless, the sensation will pass in about 30 seconds. However, if she then sits up, the phenomenon recurs, although less severely, this time with the environ- ment moving from left to right and a sensation of falling to the left. There is no history of hearing loss or tinnitus, nor is there an asso- ciated diplopia, dysarthria, or weakness. On examination, vital signs including orthostatic blood pressure and heart rate determinations are normal. General examination and routine neurologic examination are normal. The findings on examination of cranial nerve VIII include normal auditory acuity, air better than bone conduction, and intact speech discrimination. There is no spontaneous nystagmus. However, with Dix-Hallpike position testing, tortional nystagmus develops three seconds after the patient attains the right-ear- down position, with fast phase in the counter-clockwise direction as viewed from the perspective of the examiner. In addition, there is a vertical component to the nystagmus in the left eye with the fast phase upward. The patient reports verti- go, with the environment spinning right to left, which she says is the same as her symptoms at home. The nystagmus and vertigo stop after 30 seconds, but when she sits up, there are a few beats of nystagmus in the opposite direction with recurrence of verti- go but in the reverse direction. Head-hanging and left-ear-down positions fail to elicit vertigo or nystagmus. (Resolution of this case is described at the end of this article.) detail in the October 2006 issue of JUCM, and will not be explored further here. Disequilibrium “My balance is off and I feel as if I might fall.” This ver- sion of dizziness generally reflects one of two major categories of neurologic disease, apart from disorders of the vestibular system. Cerebellar ataxia is due either to a primary disease of the cerebellum (e.g., cerebellar degeneration, tumor in or near the cerebellum, cerebellar infarct) or disorders of the tracts leading to (cerebellopetal) or from (cere- bellofugal) the cerebellum. Neurologic examination will ordinarily unveil such pathology by revealing axial (e.g., wide-based gait; falling to one side) or appendicu- lar ataxia (e.g. side-to-side tremor on goal-directed action). Multiple sensory deficits syndrome is due to several abnormalities in the various sensory proprio- ceptive systems. When a number of these systems fail, the central nervous system receives conflicting proprio- ceptive input, with consequent dizziness. Typically, such a patient complains of dizziness at night—for instance, when the lights are out or dim and he or she has to go to the bathroom. On occasion, the patient may fall, partic- ularly in environments in which there are no reliable visual cues (e.g., the shower). The treatment of this extremely common syndrome is common sense (as many of the sensory abnormalities that can be corrected should be); such patients should w w w. j u c m . c o m not be treated with drugs that might sedate them, as antivertigo medications would do. Mistaking this syn- drome for vertigo would, in fact, make matters worse. Anxiety and/or Depression There are patients who when asked, “What do you mean, dizzy?” respond, usually after a pause, “Dizzy.” If the physician persists with “Do you mean you might faint?” or “Do you mean that you might fall?” or “Do you mean that the room spins?” the patient repeats, “No, I mean I’m dizzy.” This disorder can only be called true dizziness, and it generally arises from various psychological disorders, most commonly anxiety (with or without hyperventila- tion) and/or depression. Vertigo The fourth and last category of disorder found in patients who complain of dizziness is true vertigo (an illusion or hallucination of motion). Some patients insist that they themselves are moving, while others— such as the one presented above—have the sense that the environment is moving. In either case, these patients transmit the message that they feel as if they are tilting, rocking, falling, spinning, or moving in some fashion. Vertigo indicates a disturbance in the vestibular sys- tem. The important clinical question is whether the vertigo is due to a disorder in the peripheral nervous sys- tem or in the central nervous system, for central and JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 7 11