What are the recommended next steps for a middle-aged male with no known pre-existing medical conditions, who fell on his back 6 days ago and has been experiencing vague dizziness for 4 days, with concerns about a potential head injury?

Immediate Clinical Assessment and Management

This patient requires a focused evaluation to distinguish between post-traumatic benign paroxysmal positional vertigo (BPPV), which is highly likely given the trauma history and delayed onset of positional symptoms, versus more serious central causes that would present with additional neurologic signs. The key is performing a Dix-Hallpike maneuver and targeted neurologic examination rather than imaging or extensive workup 1, 2.

First Priority: Characterize the Dizziness

Determine if this is true vertigo (spinning sensation) versus vague lightheadedness or unsteadiness, as elderly patients often struggle to articulate symptoms clearly 1. Ask specifically:

• Does he feel like the room is spinning around him, or does he feel like he might faint? A confident description of spinning indicates inner ear dysfunction, while feeling faint suggests presyncope 1
• How long do episodes last? Seconds-only duration strongly suggests BPPV, while minutes-duration raises concern for stroke/TIA 1
• What triggers the dizziness? Changing head position (rolling over in bed, looking up, bending down) is classic for post-traumatic BPPV 1

Essential Physical Examination

Perform the Dix-Hallpike maneuver immediately - this is the single most important diagnostic test for BPPV, which has a significantly higher recurrence rate after trauma 3. The test involves:

1. Sitting the patient upright on the examination table
2. Turning his head 45 degrees to one side
3. Rapidly lowering him backward to a supine position with head hanging 20 degrees below horizontal
4. Observing for rotatory nystagmus and reproduction of vertigo symptoms 1

Conduct a focused neurologic examination to exclude stroke, including 1, 2:

• Cranial nerve testing (facial symmetry, eye movements, tongue deviation)
• Cerebellar testing (finger-to-nose, heel-to-shin)
• Gait assessment (observe him walking)
• Assessment for focal motor or sensory deficits

Critical pitfall to avoid: Up to 80% of posterior circulation stroke patients may have NO focal neurologic signs, so absence of deficits does not rule out stroke 1. However, the 6-day delay with only vague dizziness for 4 days makes acute stroke extremely unlikely.

Fall Risk Assessment

Evaluate fall risk systematically since BPPV increases fall risk 12-fold, and 75% of elderly patients with undiagnosed BPPV had fallen within 3 months 1, 2. Ask:

• Has he fallen before this incident? 3
• Does he feel unsteady when standing or walking? 2
• Is he worried about falling? 2
• How long did he remain on the ground after the cow incident? Prolonged time on ground indicates inability to self-rescue 3

Imaging Decision

No imaging is needed if the Dix-Hallpike is positive for BPPV and neurologic examination is normal 2. The American College of Radiology specifically recommends against imaging for brief episodic vertigo with typical BPPV features 2.

Reserve MRI brain for 2:

• Abnormal neurologic examination findings
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• High vascular risk with acute vestibular syndrome

Neuroimaging has little value in BPPV, with MRI testing not contributory to clinical diagnosis in a retrospective cohort of 2,374 patients 1.

Immediate Treatment if BPPV Confirmed

Perform the Epley maneuver (canalith repositioning procedure) immediately if Dix-Hallpike is positive - this has a 90-98% success rate 2, 4, 5. This involves a series of head and body position changes to move displaced otoconia back to their proper location.

Counsel him specifically about 3:

• Higher recurrence risk after trauma - post-traumatic BPPV has an even higher recurrence rate than spontaneous BPPV 3
• Fall prevention strategies: Sit or lie down immediately when dizzy, use assistive devices if balance affected, avoid sudden head movements 2
• Return precautions: Come back if symptoms worsen, new neurologic symptoms develop (hearing loss, severe headache, difficulty walking, nausea/vomiting), or if dizziness doesn't improve after treatment 3

Addressing His Anxiety

Reassure him that BPPV is benign and highly treatable 3. The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that explaining the diagnosis helps put patients at ease, as the acute onset of vertiginous symptoms can mimic stroke and is very frightening 3. A thorough neurologic examination and simple Dix-Hallpike test can reliably identify BPPV, making expensive testing unnecessary 3.

Medication Considerations

Avoid vestibular suppressants like meclizine for BPPV - while FDA-approved for vertigo associated with vestibular system diseases 6, pharmacologic intervention is limited because it affects the central nervous system's ability to compensate for dizziness 5. The Epley maneuver is far more effective 2, 4.

Follow-up Plan

Arrange follow-up within 1-2 weeks to reassess symptoms and perform repeat Dix-Hallpike if needed 3. If symptoms persist despite treatment, consider vestibular rehabilitation therapy 4, 5. Ensure he has expedited access to care if symptoms recur, given the high recurrence rate in post-traumatic BPPV 3.