What are key points to cover in the History of Present Illness (HPI) for a patient presenting with vertigo in a hospital setting?

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Last updated: December 31, 2025View editorial policy

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HPI Pointers for Vertigo Workup in Hospital Setting

First Critical Distinction: Define the Symptom Type

Your initial task is to determine if the patient has true vertigo (sensation of spinning or rotational movement) versus vague dizziness, lightheadedness, or presyncope. 1

  • True vertigo = spinning sensation is specific for inner ear dysfunction 1
  • Feeling like fainting or passing out = presyncope, NOT vertigo 1
  • Unsteady or off-balance without spinning = dizziness, not true vertigo 1
  • Do not rely on the patient's vague description of "dizziness"—focus instead on timing, triggers, and associated symptoms 2

Essential Timing Questions (Most Diagnostically Valuable)

Duration of episodes is the single most important feature that distinguishes causes: 1

  • Seconds only (<1 minute) = BPPV (benign positional vertigo) 1, 2
  • Minutes duration = possible stroke/TIA or vestibular migraine 1, 2
  • Hours = Ménière's disease or vestibular migraine 3
  • Days to weeks (constant) = vestibular neuritis, labyrinthitis, or stroke 2, 3

Triggering Factors to Document

  • Head position changes (rolling over in bed, looking up, bending down) strongly suggest BPPV 1, 2
  • Pressure changes (coughing, sneezing, straining) suggest superior canal dehiscence or perilymph fistula 2
  • No specific trigger with spontaneous onset suggests vestibular neuritis or central causes 2

Associated Symptoms (Critical for Differential)

Auditory symptoms:

  • Hearing loss, tinnitus, or aural fullness = Ménière's disease or labyrinthitis 2, 3
  • Sudden unilateral hearing loss = labyrinthitis or stroke (red flag requiring urgent evaluation) 2, 3
  • Pulsatile tinnitus = vascular malformation or dissection (requires CTA) 2

Neurological symptoms (RED FLAGS):

  • Dysarthria, dysphagia, visual blurring, drop attacks, limb weakness/numbness = posterior circulation stroke until proven otherwise 3
  • New severe headache = mandates immediate imaging and neurologic consultation 2
  • Focal neurological deficits = central cause requiring urgent MRI 2, 3

Migraine features:

  • Headache, photophobia, phonophobia suggest vestibular migraine 2
  • History of migraine headaches is relevant (34% of BPPV patients have migraine history) 1

Nystagmus Characteristics to Document

Peripheral (benign) patterns:

  • Horizontal or rotatory nystagmus that lessens with visual fixation 1
  • Latency of 5-20 seconds before onset, resolves within 60 seconds 2

Central (dangerous) patterns requiring immediate imaging:

  • Direction-changing nystagmus without head position changes 2, 3
  • Downbeating nystagmus 1, 2, 3
  • Gaze-holding, direction-switching nystagmus 1
  • Nystagmus that does NOT lessen with visual fixation 4

Vascular Risk Factors to Assess

  • Age >50, hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation 1, 2
  • High vascular risk patients with acute vestibular syndrome require MRI even without focal deficits 2

Medication Review (Leading Reversible Cause)

Document all medications, particularly: 1, 2

  • Antihypertensives (diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates)
  • Sedatives and anticonvulsants
  • Psychotropic drugs (antipsychotics, tricyclic antidepressants, antihistamines)

Fall History and Functional Impact

  • Previous falls (dizziness increases fall risk 12-fold in elderly) 1
  • Fear of falling or unsteadiness 1
  • Among elderly with BPPV, 75% had fallen within prior 3 months 1

Trauma History

  • Head trauma can cause posttraumatic vertigo that persists chronically with vertigo, disequilibrium, tinnitus, and headache 2

Psychiatric Screening

  • Anxiety, panic disorder, depression are common causes of chronic vestibular syndrome 2

Critical Pitfall to Avoid

Never assume absence of focal neurologic deficits rules out stroke—75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits. 2, 3 This is why the HINTS examination (when performed by trained practitioners) has 100% sensitivity for detecting stroke versus early MRI at only 46% sensitivity. 2

References

Guideline

Evaluating Vertigo in the Elderly

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Evaluation of Dizziness Based on Cited Facts

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Differential Diagnosis of Vertigo with Fever and Cough

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Initial evaluation of vertigo.

American family physician, 2006

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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