What is the appropriate history of present illness (HPI) for a patient presenting with dizziness?

Comprehensive History of Present Illness for Dizziness

A thorough history of present illness for dizziness should focus on timing, triggers, and associated symptoms rather than the patient's subjective description of the sensation, as this provides the most clinically useful information for diagnosis and treatment. 1, 2

Key Components of Dizziness HPI

1. Timing and Pattern

• Onset: Sudden vs. gradual
• Duration: Seconds, minutes, hours, or days
• Frequency: Single episode vs. recurrent episodes
• Chronicity: Acute, episodic, or chronic

2. Triggers and Exacerbating Factors

• Positional changes: Head movements, rolling over in bed, looking up or bending down (suggests BPPV) 1
• Specific head positions that provoke symptoms
• Environmental triggers: Crowded/warm places, prolonged standing 1
• Activity-related: During/after exercise, urination, defecation, cough, or swallowing 1
• Auditory stimuli: Loud noises, specific tones

3. Associated Symptoms

• Auditory symptoms:

  • Unilateral hearing loss or tinnitus (suggests Ménière's disease) 1
  • Aural fullness
  • Bilateral auditory complaints (may suggest vestibular migraine) 1

• Neurological symptoms:

  • Visual disturbances or aura (suggests vestibular migraine) 1
  • Focal weakness or numbness (suggests central cause) 1
  • Speech or swallowing difficulties (suggests central cause)
  • Diplopia (suggests central cause)

• Autonomic symptoms:

  • Nausea/vomiting
  • Sweating
  • Pallor
  • Palpitations before syncope (suggests cardiac cause) 1

4. Alleviating Factors

• Rest
• Medications
• Specific positions
• Time course of symptom resolution

5. Quality of Sensation

While less reliable than timing and triggers, document:

• Spinning (vertigo)
• Lightheadedness
• Imbalance/disequilibrium
• Feeling of impending faint (presyncope)

6. Impact on Function

• Effect on daily activities
• Falls or near-falls
• Need for assistance with ambulation
• Work/driving limitations

Risk Factors and Medical History

1. Cardiovascular Risk Factors

• Hypertension
• Diabetes
• Hyperlipidemia
• Smoking
• Prior stroke or TIA
• Arrhythmias or heart disease 1

2. Medication Review

• Antihypertensives
• Anticonvulsants
• Sedatives
• Antidepressants
• Diuretics
• Vestibular suppressants
• Recent medication changes 1

3. Past Medical History

• Previous episodes of dizziness
• History of migraine (essential to assess for vestibular migraine) 1
• Ear disorders or surgeries
• Neurological disorders
• Psychiatric disorders (anxiety, depression)
• Recent infections (especially upper respiratory)

Common Pitfalls to Avoid

1. Relying solely on the patient's description of "dizziness" - Patients often use this term imprecisely; focus on timing, triggers, and associated symptoms instead 2

2. Failing to assess for BPPV - This is the most common cause of vertigo and can be easily diagnosed with the Dix-Hallpike maneuver 1

3. Missing red flags for central causes - New headache, diplopia, dysarthria, dysphagia, or focal neurological deficits require urgent evaluation 1

4. Overlooking vestibular migraine - A common cause of dizziness that can mimic Ménière's disease; assess for history of migraine, photophobia, and motion intolerance 1

5. Excessive testing - Routine neuroimaging has low yield in patients with typical peripheral vertigo; reserve for those with neurological signs or atypical presentations 1

By systematically collecting this information, clinicians can effectively categorize dizziness and determine appropriate next steps for evaluation and management, prioritizing the identification of serious but treatable conditions that could affect morbidity and mortality.