What is the next course of action for a 63-year-old male with vertigo, who recently started Augmentin (amoxicillin/clavulanate) for a sinus infection, and has a history of bilateral lower extremity (BLE) swelling due to Imbruvica (ibrutinib), with normal ejection fraction (EF) and previously prescribed Furosemide (furosemide)?

Vertigo Management in This Patient

Your immediate next step is to perform a focused clinical assessment to distinguish between benign positional vertigo (most likely), central/stroke causes (most dangerous), and medication-related dizziness, starting with the Dix-Hallpike maneuver and HINTS examination to rule out stroke before attributing symptoms to Augmentin or other causes. 1, 2, 3

Critical Initial Assessment

Define the Vertigo Characteristics

• Ask about precise duration of episodes - this single feature distinguishes most causes: seconds suggests BPPV, minutes suggests stroke/TIA or vestibular migraine 2
• Determine if true spinning vertigo versus vague dizziness - elderly patients often present with atypical "vestibular disturbance" rather than frank spinning, and this patient's age (63) puts him at higher risk for atypical presentations 2
• Identify triggering factors - specifically ask if changing head position triggers symptoms, which would suggest BPPV 2

Perform Essential Physical Examination

• Execute the Dix-Hallpike maneuver immediately - this diagnoses BPPV, the most common cause of vertigo in this age group 1, 2
• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) - this has 100% sensitivity for detecting stroke when properly performed, far superior to early MRI (46% sensitivity) 2, 3
• Assess nystagmus patterns carefully - downbeating nystagmus, direction-changing nystagmus without head position changes, or gaze-holding nystagmus all suggest central/stroke causes requiring urgent intervention 1, 2, 3

Complete Neurologic Examination

• Perform focused posterior circulation assessment including cranial nerves, cerebellar testing (finger-to-nose, heel-to-shin, gait), and sensory/motor examination 2, 3
• Do not be falsely reassured by absence of focal deficits - up to 80% of stroke patients with acute vestibular syndrome may have no focal neurologic signs 2, 3

Risk Stratification for This Patient

High-Risk Features Present

• Age 63 with cardiovascular risk factors - patients on ibrutinib have increased cardiovascular risk, and cerebrovascular disease prevalence in acute vestibular syndrome can be 25-75% in high vascular risk cohorts 3
• Active infection (sinusitis) - systemic infection can increase stroke risk
• Recent medication changes - Augmentin started "a couple of days" before vertigo onset

Consider Stroke Until Proven Otherwise

• Stroke accounts for 3-7% of all vertigo cases but much higher in elderly with vascular risk factors 4
• Posterior circulation strokes frequently present with isolated vertigo - 10% of cerebellar strokes present similar to peripheral vestibular processes 1
• CT imaging is inadequate - never rely solely on CT for suspected stroke as it frequently misses posterior circulation strokes 2, 3

Management Algorithm Based on Findings

If Dix-Hallpike Positive and HINTS Reassuring (Peripheral Cause)

• Perform canalith repositioning procedure (Epley maneuver) immediately - this is first-line treatment for BPPV 1, 5
• Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) - these are not recommended for BPPV treatment as they interfere with central compensation and have no evidence for efficacy 1
• Reserve vestibular suppressants only for severe nausea/vomiting in severely symptomatic patients refusing other treatments 1
• Reassess within 1 month to confirm symptom resolution 1

If HINTS Concerning or Neurologic Deficits Present

• Obtain urgent MRI with diffusion-weighted imaging - this is the gold standard for posterior circulation stroke 3, 4
• Do not delay imaging based on negative CT - CT misses most posterior circulation strokes 2, 3
• Consider immediate neurology consultation for potential stroke management 3

If Examination Equivocal or Atypical Presentation

• Maintain high index of suspicion for stroke given age and risk factors 3, 4
• Consider MRI even with reassuring initial examination - failure to respond to standard vestibular treatments suggests central cause 1
• Assess for vestibular migraine - this accounts for 14% of vertigo cases and has lifetime prevalence of 3.2%; requires history of migraine and episodes lasting 5 minutes to 72 hours 1

Medication Review

Augmentin Considerations

• Augmentin rarely causes true vertigo - dizziness is listed as a side effect but typically represents lightheadedness rather than spinning vertigo 6
• Timing is suspicious (started days before vertigo) but does not rule out other causes
• Do not discontinue Augmentin prematurely if treating active sinusitis unless vertigo clearly medication-related and other causes excluded

Other Medications to Consider

• Furosemide can cause dizziness through volume depletion and orthostatic hypotension 1
• Check orthostatic vital signs - measure blood pressure supine and standing to assess for postural hypotension 5
• Ibrutinib increases cardiovascular risk - maintain heightened awareness for stroke 3

Critical Pitfalls to Avoid

• Never assume absence of focal deficits rules out stroke - up to 80% of stroke patients with acute vestibular syndrome lack focal signs 2, 3
• Never rely on CT alone for stroke evaluation in vertigo patients 2, 3
• Never prescribe vestibular suppressants as primary BPPV treatment - they are ineffective and delay compensation 1
• Never attribute vertigo to medications without excluding dangerous causes first - stroke must be ruled out in this age group 3, 4

Falls Risk Assessment

• Screen for falls risk immediately - elderly patients with vertigo have 12-fold increased risk for falls 3
• Assess home support and mobility limitations - these modify management approach 1, 3
• Provide falls precautions regardless of etiology until symptoms resolve 1, 3