A patient reports dizziness when bending over and had a recent fall; orthostatic blood pressures are normal without a significant drop. How should an outpatient nurse practitioner evaluate and manage this presentation?

Evaluation and Management of Positional Dizziness with Normal Orthostatic Vitals

This patient does not have orthostatic hypotension and requires evaluation for alternative causes of positional dizziness, most likely benign paroxysmal positional vertigo (BPPV) or other vestibular disorders, given the specific symptom of dizziness when bending over.

Why This Is Not Orthostatic Hypotension

Your patient's vital signs do not meet diagnostic criteria for orthostatic hypotension:

• Classical orthostatic hypotension requires a sustained drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing 1
• Your patient's measurements show: Lying 124/70 → Sitting 112/68 → Standing 116/66
• The systolic drop from lying to sitting is only 12 mmHg, and standing BP actually increases to 116 mmHg 2
• This pattern is normal physiologic variation, not pathologic orthostatic hypotension 2

Critical Distinction: Dizziness When Bending Over vs. Standing

The patient's specific complaint of dizziness when bending over is inconsistent with orthostatic hypotension, which causes symptoms upon standing up, not bending forward 1, 3. This symptom pattern strongly suggests:

• Benign paroxysmal positional vertigo (BPPV) - the most common cause of positional vertigo triggered by head position changes including bending
• Other vestibular disorders affecting the inner ear
• Cervical vertigo from neck position changes

Your Immediate Evaluation Should Include

Focused History Elements

• Characterize the dizziness precisely: Is it true vertigo (room spinning) versus lightheadedness versus imbalance? 1
• Timing and triggers: Does it occur only with bending, or also with rolling over in bed, looking up, or other head movements?
• Duration: BPPV episodes typically last seconds to minutes, not hours 1
• Associated symptoms: Nausea, hearing loss, tinnitus, or ear fullness suggest vestibular pathology 1
• Medication review: Check for any vasoactive medications, diuretics, or psychotropic drugs that could contribute to falls 3

Physical Examination Priorities

• Perform Dix-Hallpike maneuver to diagnose BPPV - this is the single most important test for positional vertigo triggered by bending
• Cardiovascular examination: Auscultate for murmurs suggesting valvular disease or cardiac outflow obstruction 4
• Neurological examination: Assess for focal deficits, cerebellar signs, or evidence of autonomic dysfunction 3
• Gait assessment: Observe for ataxia or balance impairment that increases fall risk

Essential Diagnostic Testing

• 12-lead ECG to detect arrhythmias, conduction abnormalities, or structural heart disease 4
• Consider basic labs only if clinically indicated: Complete blood count (anemia), basic metabolic panel (electrolytes), glucose 4

Management Approach

If BPPV Is Confirmed

• Perform Epley maneuver (canalith repositioning) in the office - this is curative in 80% of cases with a single treatment
• Teach home exercises (Brandt-Daroff exercises) if symptoms persist
• Reassure the patient this is benign and treatable

If Vestibular Disorder Is Suspected But Unclear

• Refer to ENT or neurology for specialized vestibular testing
• Consider vestibular suppressants (meclizine) for symptomatic relief only during acute episodes, not long-term

Fall Prevention Regardless of Cause

• Educate about fall risk and environmental modifications (remove tripping hazards, adequate lighting, grab bars) 5
• Review all medications for those that increase fall risk (sedatives, anticholinergics, antihypertensives) 3
• Consider physical therapy for balance training if recurrent falls

Important Caveats

Do not diagnose orthostatic hypotension based on these vitals - approximately 95% of true orthostatic hypotension cases meet the systolic criterion alone, and your patient does not 6. The small BP variations you measured are within normal physiologic range 2.

Many patients with true orthostatic hypotension are asymptomatic - up to 63% of patients with documented orthostatic hypotension have no symptoms during measurement 7. However, your patient has symptoms but no orthostatic BP drop, pointing away from this diagnosis.

The specific trigger of "bending over" is the key diagnostic clue - this is classic for BPPV or other vestibular pathology, not cardiovascular causes 1. Don't be distracted by the recent fall; focus on the mechanism of the dizziness itself.