What is the approach to taking a comprehensive history of present illness (HPI) and performing a physical examination (PE) for a patient presenting with a chief complaint (CC) of dizziness?

Dizziness HPI and Physical Examination Template

History of Present Illness Framework

Focus on timing and triggers rather than the patient's subjective description of "dizziness," as this approach is more diagnostically valuable and distinguishes benign peripheral causes from dangerous central pathology like stroke. 1, 2

Critical Timing Questions (Ask First)

• Duration of episodes: Seconds (<1 minute suggests BPPV), minutes to hours (suggests Ménière's disease or vestibular migraine), hours to days (suggests vestibular neuritis or stroke), or chronic/constant (suggests medication effect, anxiety, or CNS pathology) 1, 2, 3

• Onset pattern: Sudden vs gradual, first episode vs recurrent 2, 3

• Frequency: How often episodes occur, pattern over time 4

Trigger Identification (Critical for Classification)

• Positional triggers: Does turning head, rolling over in bed, looking up, or lying down provoke symptoms? (suggests BPPV) 2, 3

• Spontaneous episodes: Do symptoms occur without any trigger? (suggests vestibular neuritis, Ménière's, vestibular migraine, or stroke) 2, 3

• Movement sensitivity: Does walking or head movement worsen symptoms? 4

Associated Symptoms (High Diagnostic Value)

• Auditory symptoms: Hearing loss (fluctuating vs constant), tinnitus (unilateral, bilateral, or pulsatile), ear fullness or pressure (suggests Ménière's disease if present together) 4, 2

• Neurological red flags: Focal weakness, numbness, diplopia, dysarthria, dysphagia, ataxia, or altered mental status (suggests stroke) 1, 2

• Headache characteristics: New severe headache, photophobia, phonophobia (vestibular migraine if present; stroke if new and severe) 4, 2

• Near-syncope or presyncope: Feeling faint, vision darkening, or loss of consciousness (suggests cardiovascular cause) 1

Fall History and Functional Impact

• Previous falls: Number, circumstances, injuries sustained 1

• Time spent on floor/ground after fall: Inability to get up suggests severe impairment 1

• Current mobility: Feeling unsteady when standing or walking, need for assistive devices 1

• Worry about falling: Indicates functional impact and fall risk 1

Vascular Risk Stratification

• Age >60 years, hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation, prior stroke/TIA (high vascular risk mandates different imaging threshold) 2

Medication Review (Leading Reversible Cause)

• Antihypertensives, sedatives, anticonvulsants, psychotropic drugs are common culprits in chronic dizziness 2

Psychiatric Screening

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

Trauma History

• Head trauma with persistent symptoms suggests posttraumatic vertigo 2

Physical Examination Template

Vital Signs and Orthostatic Assessment

• Orthostatic blood pressure measurement: Check supine, then after 1 and 3 minutes of standing 5

Otologic Examination

• Otoscopy: Examine tympanic membranes for effusion, perforation, cholesteatoma 2

Neurological Examination (Critical for Risk Stratification)

• Cranial nerves: Particular attention to CN III, IV, VI (eye movements), CN V (facial sensation), CN VII (facial strength), CN VIII (hearing), CN IX-XII 5

• Cerebellar testing: Finger-to-nose, heel-to-shin, rapid alternating movements 5

• Gait assessment: Observe walking, tandem gait, Romberg test 5

• Motor and sensory examination: Look for focal deficits 5

Critical caveat: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have NO focal neurologic deficits, so normal exam does not exclude stroke. 2

Vestibular-Specific Examination

For Triggered Episodic Symptoms (Suspected BPPV)

• Dix-Hallpike maneuver (gold standard): Positive findings include 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms that increase then resolve within 60 seconds 2, 3

• Supine roll test: For horizontal canal BPPV 3

For Acute Persistent Vertigo (Suspected Vestibular Neuritis vs Stroke)

HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 1, 2

• Head Impulse Test: Abnormal (corrective saccade) suggests peripheral; normal suggests central cause 2

• Nystagmus pattern: Unidirectional horizontal nystagmus suggests peripheral; direction-changing, vertical, or purely torsional suggests central 2

• Test of Skew: Vertical misalignment (skew deviation) suggests central cause 2

Warning: HINTS is less reliable when performed by non-experts; if uncertain, treat as high-risk and image. 2

Balance and Fall Risk Assessment

• Get Up and Go test: Time patient rising from chair, walking 10 feet, turning, returning, and sitting 1

• Tinetti Balance Assessment: Structured balance evaluation 1

• Berg Balance Scale: Comprehensive balance testing 1

Among elderly patients with undiagnosed BPPV, 75% had fallen within prior 3 months, highlighting importance of fall risk assessment. 1

Nystagmus Assessment

• Observe at rest and with gaze in all directions: Note direction, pattern (horizontal, vertical, torsional, rotatory), and whether it changes with gaze direction 5, 3

• Downbeating nystagmus or other central patterns: Red flag requiring urgent evaluation 1, 2

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits 1, 2
• Sudden hearing loss 1, 2
• Inability to stand or walk 1, 2
• New severe headache 2
• Downbeating nystagmus or central nystagmus patterns 1, 2
• Abnormal HINTS examination suggesting central cause 1, 2
• High vascular risk with acute vestibular syndrome 2
• Failure to respond to appropriate vestibular treatments 2

Common Pitfalls to Avoid

• Do not rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 2

• Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes present without focal deficits 2

• Do not perform HINTS examination if not properly trained—unreliable results may lead to missed strokes 2

• Do not order routine imaging for typical BPPV with positive Dix-Hallpike—it delays treatment and has low yield 2

• Do not use CT instead of MRI when stroke is suspected—CT misses many posterior circulation infarcts 2