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The clinician should find out what the dizzy patient is experiencing, as accurately as possible. A common clinical error is to label all dizziness as "vertigo." Is there a sense of motion, either of one's own body or of one's surroundings? If so, true vertigo exists. The history in this case is usually clearer than with other forms of dizziness. The patient often vividly recollects when and where the first episode occurred, describing the spinning sensation and, usually, the accompanying nausea. If this is not the picture, one should ask the patient to describe the symptoms without using the word "dizzy." A good question is: "Does it feel like you or the room is moving or going around?" If an affirmation confirms that vertigo is indeed present, the problem almost certainly arises from the vestibular labyrinth or its connections in the brainstem.

Whether or not there is true vertigo, other questions regarding the patient's symptoms are in order. The circumstances of the onset of the first episode, its length, precipitating factors, and patterns of persistence

Romberg Assessment

Fig. 8.1a and b The Romberg test. The patient is instructed to stand erect with the eyes closed, the feet slightly apart, and the arms folded. A peripheral labyrinthine lesion will cause swaying to the affected side (a); a central disorder is more likely to cause random imbalance in any direction (b).

(Source: Becker W, Naumann HH, Pfaltz CR. Ear, Nose, and Throat Diseases. Stuttgart: Thieme; 1994)

Fig. 8.1a and b The Romberg test. The patient is instructed to stand erect with the eyes closed, the feet slightly apart, and the arms folded. A peripheral labyrinthine lesion will cause swaying to the affected side (a); a central disorder is more likely to cause random imbalance in any direction (b).

(Source: Becker W, Naumann HH, Pfaltz CR. Ear, Nose, and Throat Diseases. Stuttgart: Thieme; 1994)

or recurrence all help point to a possible diagnosis. Are ear symptoms present?

Physical examination of the dizzy patient should include an assessment of balance and extraocular motion, as well as of the ears and hearing. One should look for nystagmus, especially during position change. The Hallpike maneuver is discussed later in this chapter. The Romberg test (Figs. 8.1a and b) should be done. With peripheral vestibular lesions, the patient tends to sway to the side of the diseased labyrinth, whereas in central balance disorders, the direction of sway is random. The sections on specific vestibular disorders discuss physical and test findings in greater detail. The most important diagnostic tool, however, is an accurate history taken by a caregiver who is aware of the disease entities to be discussed.

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