The Dizzy Patient: Taking a Comprehensive, Yet Concise Case History

Patients who enter your clinic with dizziness and imbalance are typically coming in with a very complex case history. The vestibular anatomy and physiology is considerably complex and the disorders that result can present themselves in a number of different ways. This is why obtaining a comprehensive case history is critical for a successful diagnosis. For a student starting out in a vestibular clinic, it can be hard to know which questions to ask and how to get a comprehensive history as quickly as possible in the busy clinical setting. Below is an example of information to obtain during an initial case history appointment. Although neither an exhaustive list nor an all-inclusive list, it can be a great place to start if you’re new to the vestibular sciences.

One of the first things you’ll want to figure out about your patient is whether they are experiencing true vertigo, lightheadedness, or imbalance. Many people and healthcare professionals use the word “dizziness” as a catch-all symptom or diagnosis. We, as vestibular professionals, know that dizziness is much more complicated and can manifest in a variety of symptoms. Which of the following sensations does your patient experience?

• True vertigo – described as room-spinning dizziness
• Lightheadedness – feeling faint or weak
• Off-balanced – feeling unsteady or unstable

A good next step is finding out the time course of the patient’s symptoms: When did the symptoms start? How frequently does your patient experience symptoms? How long do symptoms persist during each episode? Determining the time course of the symptoms can differentiate disorders. Common vestibular disorders, for the most part, are pretty well categorized by symptoms and associated durations. For example, if the patient reports a room-spinning vertigo episode that lasts less than 30 seconds and provoked by head position, your index of suspicion for a particular disorder (any guesses what?) should increase dramatically.

Once you have an idea of when these symptoms are occurring, it’s a good idea to ask the patient about any associating and/or provoking factors. Things to consider are numbness/tingling of the hands, face, or extremities, hip or knee replacements, falls, head injuries, vision concerns, hyper/hypo tension, migraines, sensitivity to light or sound, visual auras. Also, is the patient’s dizziness positional in nature? Does the patient experience these sensations in visually complex environments and/or scrolling on their phone or computer? As audiologists, we need to also be concerned with any ear-related symptoms such as tinnitus, aural fullness, pressure, hearing fluctuations, and surgical history.

The information gained from a comprehensive, yet efficient case history interview can not only help direct the clinic plan but also aid in your final diagnosis. Using crucial information obtained during the case history may aid in the differential diagnosis. This is essential since, as the professional, you will determine what course of action is taken to address the patient’s dizziness and imbalance. At the end of the day, we are assessing reflexes at a given point in time during vestibular assessment. And one thing to always keep in mind is that our measures can vary based on a number of different variables, such as the use of vestibular suppressants and what stage of compensation the patient is in. Therefore, the importance of a detailed case history cannot be stressed enough. The information perceived from functioning and/or impaired vestibular reflexes are being expressed during the case history, making it one of the most important clinical tools you have as a clinician. As of today, the case history is essentially the only point where we are taking in the subjective perception of vestibular sensation.

Daniel J. Romero, AuD is currently working on his PhD degree with an emphasis in vestibular science at James Madison University. He obtained his Doctor of Audiology degree from Northern Illinois University in 2018. His interests include vestibular assessment and management, vestibular perception, and auditory and vestibular evoked potentials.

Liz Marler, BA is a fourth-year from Purdue University completing her externship at the Mayo Clinic in Phoenix, AZ. She is currently serving as the President of the SAA. Her interests include vestibular and electrophysiology.