title: Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo.
abstract: BACKGROUND
  Emergency department (ED) patients who present with acute dizziness or vertigo can be challenging to diagnose. Roughly half have general medical disorders that are usually apparent from the context, associated symptoms, or initial laboratory tests. The rest include a mix of common inner ear disorders and uncommon neurologic ones, particularly vertebrobasilar strokes or posterior fossa mass lesions. In these latter cases, misdiagnosis can lead to serious adverse consequences for patients.
  
  
  OBJECTIVE
  Our aim was to assist emergency physicians to use the physical examination effectively to make a specific diagnosis in patients with acute dizziness or vertigo.
  
  
  CONCLUSIONS
  Recent evidence indicates that the physical examination can help physicians accurately discriminate between benign inner ear conditions and dangerous central ones, enabling correct management of peripheral vestibular disease and avoiding dangerous misdiagnoses of central ones. Patients with the acute vestibular syndrome mostly have vestibular neuritis, but some have stroke. Data suggest that focused eye movement examinations, at least when performed by specialists, are more sensitive for detecting early stroke than brain imaging, including diffusion-weighted magnetic resonance imaging. Patients with the triggered episodic vestibular syndrome mostly have benign paroxysmal positional vertigo (BPPV), but some have posterior fossa mass lesions. Specific positional tests to provoke nystagmus can confirm a BPPV diagnosis at the bedside, enabling immediate curative therapy, or indicate the need for imaging.
  
  
  CONCLUSIONS
  Emergency physicians can effectively use the physical examination to make a specific diagnosis in patients with acute dizziness or vertigo. They must understand the limitations of brain imaging. This may reduce misdiagnosis of serious central causes of dizziness, including posterior circulation stroke and posterior fossa mass lesions, and improve resource utilization.
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Edlow
authors.affiliation: The Johns Hopkins Hospital, Department of Neurology, The Johns Hopkins University School of Medicine, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland.
authors.forename: David
authors.initials: D
authors.lastname: Newman-Toker
mesh_terms: D000208:Acute Disease; D065635:Benign Paroxysmal Positional Vertigo / Q000175:diagnosis; D003937:Diagnosis, Differential; D004244:Dizziness / Q000175:diagnosis*; D004636:Emergency Service, Hospital; D006801:Humans; D010808:Physical Examination; D020521:Stroke / Q000175:diagnosis*; D015837:Vestibular Diseases / Q000175:diagnosis*
keywords: BPPV; dizziness; misdiagnosis; physical examination; posterior circulation stroke; vertigo