The Dizzy Patient: Four By Four Approach To Intervention

The Dizzy Patient: Four By Four Approach To Intervention
Ahmad Mohd Alamadi
Department of Otolaryngology, Al Baraha Hospital Ministry of Health, United Arab Emirates

OBJECTIVE: To present a systematic approach to the practical management of the dizzy patient in the office setting. This approach is based on the experience from
the Multidisciplinary Neurotology Clinic of the University Health Network, Toronto General Hospital.

MAIN MESSAGE: The dizzy patient presents challenges in a busy clinic even for  an experienced physician. Having a consistent systematic approach will minimize the time required to reach a most probable diagnosis so that further investigations can be directed appropriately. With a carefully directed history and by following our four by four approach we have found that in > 90 % of the dizzy patients the cause can be confidently diagnosed. The distinction between dizziness and the true vertigo
can be made by allowing the patient time to describe their feelings in their own words. Patients with true vertigo have vestibular pathology which can be peripheral
or central in origin. Peripheral vestibular disorders are often associated with other inner ear symptoms such as hearing loss, tinnitus and aural fullness. Patients with central vestibular disorders are more likely to have complaints of focal neurological dysfunction, for example diplopia, dysphagia, parasthesia or paresis. Clinical examination of a dizzy patient should include a relevant otological and neurological examination.

CONCLUSION: By fallowing our four by four method physicians can diagnose majority of the dizzy patients. Special vestibular tests and diagnostic maneuvers are valuable and easy skills to learn for assessment of the dizzy patient.