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Practice Diagnosis in General Practice


BMJ 2009; 339 doi: (Published 22 September 2009) Cite this as: BMJ 2009;339:b3493

This article has a correction. Please see:

  1. Kevin Barraclough, general practitioner1,
  2. Adolfo Bronstein, professor of neuro-otology2
  1. 1Painswick GL6 6TY
  2. 2Neuro-otology Unit, Division of Neurosciences and Mental Health, Imperial College London
  1. Correspondence to: K Barraclough k.barraclough{at}

Strategies for improving the pattern recognition involved in making a correct diagnosis amount to forcing yourself to use analytic reasoning (doi:10.1136/bmj.b3490); diagnosis of vertigo is an example

A 58 year old woman presented to her general practitioner stating that she woke that day feeling that the room was moving. She had vomited twice. She seemed anxious, was slightly unsteady on her feet, and was hyperventilating. She did not have fever but had a sore throat, slight difficulty swallowing, slight hoarseness, and a red throat. The Hallpike test induced vertigo and nystagmus; the nystagmus was sustained. The general practitioner thought the likely diagnosis was either viral labyrinthitis with pharyngitis, or benign paroxysmal positional vertigo.

Hallpike positioned manouvre: Instruct the patient to keep their eyes open and stare at the examiner's nose. In each position, observe eyes for up to 30 seconds for nystagmus. With the patient sitting upright on a couch, head turned 45 degrees to the right, lie the patient down rapidly until head is dependent. Return patient to upright position.

The diagnostic dilemma

In the 1970s a classification of dizziness was developed, based on an analysis of 125 patients attending a dizziness clinic.1 2 Vertigo was defined as the illusory sense of movement or orientation, and indicates disorders of the labyrinth or brainstem; presyncope was defined as a sense of near faint, typically due to transient hypotension. Disequilibrium of the elderly is often described as a non-specific slight “unsteadiness,” particularly on turning, and indicates poor balance and strength,3 4 and lightheadedness is often associated with dysfunctional breathing or anxiety.

To distinguish vertigo from non-rotatory dizziness, this validated question may be asked: “Did you just feel light headed or did you see the world spin around as though you had just got off a playground roundabout?”5

In our case scenario, the patient has vertigo, a common condition in the community. In a postal questionnaire study of general practice patients aged 18 to 65, 7% of the 2064 responders reported true vertigo in the past year.6 A full time general practitioner may expect to see 10-20 cases of vertigo a year.7

Eliciting the symptom of vertigo …

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