approach to dizzy


Traditionally we were taught to separate dizziness into pre-syncope, vertigo and dysequilibrium as the first step towards a differential diagnosis. But studies have shown patients symptoms can’t be neatly separated into these three distinct categories. Instead we need a systematic approach to dizziness, emphasizing risk factors, associated symptoms and exacerbating factors–with ENT diagnoses at the bottom so as to not miss more important diagnoses


B: CHEST: dizzy from hypoxia

  • Collapse: pneumothorax
  • Hyperinflate: asthma/COPD
  • Effusion
  • Sick pneumonia
  • Tumour

C: CARDIOVASCULAR: dizzy from decrease perfusion

  • Cardiac arrhythmia
  • Around heart: pericardial effusion
  • RV strain: PE
  • Dysfunctional LV: MI, CHF
  • Incompetent valve, eg aortic stenosis
  • Outflow: dissection aorta, carotid, vertebral
  • Volume depletion
  • Abdominal bleed
  • Soft tissue bleed, e.g. AAA
  • Child-bearing ectopic
  • Urticarial anaphylaxis
  • Lactate sepsis
  • Addison’s
  • Rx

D: NEUROLOGIC: dizzy from CNS pathology

  • N
  • Encephalitis/meningitis
  • Unregulated pressure
  • RBC bleed/clot, especially posterior circulation
  • Onco tumour

E: ENDO: dizzy from metabolic disturbance

  • Electrolyte: glucose, sodium, potassium, magnesium



H: HEME: dizzy from ANEMIA

I: INTOX: dizzy from exposures

  • Ingest: alcohol, marijuana
  • Naturopathic
  • Treatment: cardiac (anti-hypertensives, diuretic, beta blocker, calcium channel blocker), ototoxic (aminoglycosides), psychiatric (benzo, TCA)
  • X poison: carbon monoxide

Joint, skin, bone, etc: dizzy from ENT problem –> peripheral vertigo

  • ENT: BPPV, labyrinthitis, Meniere


Putting this together, you a thorough history and physical and a systematic approach should allow you to work through the differential

  • B: assess for dyspnea, hypoxia
  • C: ECG, examen for murmur, ultrasound cardiac/IVC/abdominal, CBC/beta, consider trop/dimer/echo, consider CTA neck
  • D: thorough neurological exam (including HINTS exam), consider CT head +/- MRI for posterior circulation
  • E: check electrolytes
  • F
  • G:
  • H: check Hgb
  • I: review exposures, especially medications in the elderly
  • J: assess for peripheral vertigo


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