A Checklist for the Initial Examination of a Patient with Vertigo, Part IV
This checklist is something I came up with at the suggestion of a local family practice physician that said, “Can you give me a checklist of the things I should be looking for, with management recommendations?” A word of caution, this checklist is currently just an idea and has not been validated in any way.
Since the sensitivity and specificity of categorizing a patient as “peripheral” versus “central” is greatly increased when the screening tests are viewed in combination, it is helpful to use a checklist. As you view the checklist will note two columns. The column on the left represents findings considered to be highly specific to peripheral vestibular (labyrinthine) disorders. The column on the right represents physical signs associated with brain stem or cerebellar dysfunction. As the screening exam is carried out, the examiner should mark the appropriate box. If the examiner finds that items on the left are marked, and the right column is unmarked, it is highly likely that the patient suffers from a peripheral labyrinthine disorder. To a large degree, a brain stem or cerebellar pathology has been effectively “ruled out” by identifying that the patients complaints are most likely of peripheral labyrinthine origin. Conversely, if any of the physical signs listed in the right column are noted, brain stem or cerebellar stoke should be investigated by neuro-imaging or neurologic consultation. Physical findings in the left column suggest peripheral labyrinthine etiology. Findings in the right column suggest cerebellar or brain stem etiology. Note: My apologies for the formatting below. The columns should be side by side., but I am posting this on Memorial Day and decided not to bother the IT folks. You get the idea. A properly formatted checklist can be found in my new book on page 58.
Initial Examination Checklist for Vertigo
Peripheral versus Central
Name _______________________________________________ Date ___________________
Direction Fixed Nystagmus
Nystagmus decrease w/ fixation
Positive Head Thrust exam
Transient Positional Nystagmus
Direction Changing Nystagmus
No decrease w/ fixation
Ataxia –unable to walk unassisted
Ocular Misalignment –
Vertical Skew Deviation
Focal Neurologic Deficit
(hemiplegia, dysarthria, limb ataxia)
New Onset Severe Headache
Refer for vestibular exam
Refer for Neuro-Imaging
Refer for Neurologic Consult
Next week in the final installment on this series about cerebellar stroke (CS), we will look at some studies showing that following a specific clinical exam protocol allows for identification of patients with CS more efficiently, and far less costly, than ordering a CT or MRI scan.