Bedside exam of the dizzy patient
Adapted from
Joel A. Goebel, M.D.
Associate Professor of Otolaryngology
Director, Resident Education Program
Director, vestibular & Oculomotor Laboratory
Washington University School of Medicine,
St. Louis, Missouri

David Zee, M.D.
Professor of Neurology, Otolaryngoloty, Ophthalmology & Neurosciences
Johns Hopkins University School of Medicine
Baltimore, Maryland

Examination	What to Look For	Interpretation
Ocular Versons	Disconjugate gaze	Muscle palsy Strabismus Internuclear ophthalmoplegia (INO) Skew deviation
	Nystagmus* Best with Frenzel Lenses - Form: jerk, direction fixed, horizontal--torsional - Duration: inhibited by fixation, converggence - Direction: increased by gaze in directioon of fast phase - Fixation, convergence - Form: jerk or pendular, direction cahngiing, hirzontal, vertical, torsional - Duration: enhanced by fixation - Direction: Beats in direction of gaze - Form: Horizontal - Duration: Inhibited with convergence, eyye closure - Direction: form changing - Fixation, convergence: null point Saccadic intrusions - square waves - flutter, opsoclonus	Peripheral Central Congenital Cerebellar, PSP Paraneoplastic, viral
Smooth pursuit	Saccadic pursuit Inverted pursuit	Cerebellar, cerebral cortex, drugs, age, acuity Congenital
Saccades	Dysmetric saccades Slow or late saccades Disconjugate saccades	Cerebellar, medulla Brain stem, drugs INO
Head thrust test	Refixation saccades	Deficient VOR (unilateral, bilateral)
Dynamic visual acuity	>2 line drop	Deficient VOR (bilateral)
Fixation - suppression of   perrotary nystagmus	Nystagmus despite fixation	Cerebellar Acuity deficit
Head-shake nystagmus	Nystagmus - direction: toward stronger ear (except hhydrops) - direction: downbeat	Asymmetric VOR Central
Positional testing	Nystagmus - direction: horizontal or vertical, torsiional (CCW-R, CW-L) - latency: 5-20 seconds - duration: <60 seconds - fatiguability: fatiguable, vertigo - direction: pure vertical or torsional - no latency - long duration - no vertigo - not fatibgable	BPPN Central or peripheral
Cranial N Exam	Any deficites	Interpret in context
Fine motor control - finger nose finger - Rapid alternating movements - Counting on fingers - Heel knee shin	Dysmetria, disdiadochokinesia	lateral cerebellum
Romberg test	sway, stepout, falls	Sensory ataxia Vestibular loss Sensorimotor integration Musculoskeletal deficits Non-organic patters
Gait observations	Rhythm, arm swing, turns, sway	Ataxia, parkinsonism, musculoskeltal, non-organic
Miscellaneous - Hypervetnilation - Tragal Compression - Valsalva - Fukuda Step test	Nystagmus Body Rotation