Announcements: Neuromuscular section updated with more questions.


  • Onset?
  • Description of symptoms (lightheadedness, room spinning, walking on a boat)
  • Severity
  • Duration (brief episodes, long episodes, or constant)
  • Worse with head turning or getting up?
  • Nausea or vomiting?
  • Headache or neck pain?
  • Chest pain or palpitations?
  • Recent head or neck trauma or neck manipulations?
  • Associated ear pain, URI symptoms, aural fullness, tinnitus?
  • Hydration status?
  • Able to walk? 
  • Feel off balance or pulled to one side?
  • Associated neurologic deficits, especially ataxia and brainstem symptoms (diplopia or other visual changes, tongue heaviness, taste changes, changes in voice, trouble chewing or swallowing

 EXAM: orthostatics if indicated, physical exam including otoscopic exam, full neurologic exam including detailed brainstem exam (include taste, LT and PP sensation of face, gag, tongue and uvula deviation, skew deviation of eyes), nystagmus (direction, extinguishing or not), head impulse test, Dix-Hallpike test, as well as cerebellar testing and gait exam

 WORKUP: to be dictated as above

If there are red flags or you cannot rule out central etiology, obtain neuro-imaging such as non-contrast head CT, CTA neck up to circle of Willis, and admission to rule out posterior circulation stroke. Following admission, obtain MRI to rule-out stroke.

 If no red flags and symptoms suggest BPPV or other benign etiology:

  • IV fluids
  • Meclizine (25-100 mg/day in divided doses) or Valium (5-10 mg q3-4 hr PRN)
  • Antiemetic (raglan or zofran)
  • Teach Epley maneuver and give them a handout or PT for vestibular rehab
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