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Take a practice exam on the topic: TITLE : iHUMAN CASE STUDY FRANCES DRAKE-CHAMBERLAIN DIZZINESS ENCOUNTER - COMPREHENSIVE EXAM NOTES

iHUMAN CASE STUDY: FRANCES DRAKE-CHAMBERLAIN
DIZZINESS ENCOUNTER - COMPREHENSIVE EXAM NOTES
Full Subjective and Objective Assessment, Evidence-Based SOAP Notes,
Differential Diagnoses, Final Diagnosis, Management Plan, and Patient Education
CASE OVERVIEW AND PATIENT IDENTIFICATION
Patient Demographics
Name: Frances Drake-Chamberlain
Age: 68 years old
Sex: Female
Reason for Encounter: Dizziness
Case Year: 2026
Setting: iHuman Virtual Clinical Encounter
Chief Complaint (CC)
Patient presents with complaint of dizziness.
SUBJECTIVE ASSESSMENT - HISTORY OF PRESENT ILLNESS (HPI)
OPQRST Framework for Dizziness Evaluation
Onset
Question to explore: When did the dizziness first start?
Key considerations:
- Sudden vs. gradual onset
- First episode vs. recurrent episodes
- Any triggering event (head trauma, URI, medication change)
Provoking/Palliating Factors
Provoking factors to assess:
- Position changes (lying down, rolling over, standing up)
- Head movements (turning head, looking up)
- Standing from sitting/supine position
- Stress or anxiety
- Specific foods (caffeine, salt, alcohol)
Palliating factors to assess:
- Remaining still
- Closing eyes
- Lying down in specific position
- Medication effectsQuality of Dizziness Critical First Question: "What do you mean by dizzy?"
Patients use "dizziness" to describe different sensations:
Type | Description | Likely Etiology

Vertigo | Sensation of rotation, tipping, or motion (spinning) | Vestibular
Presyncope | Feeling of passing out, losing consciousness |
Cardiovascular/autonomic
Disequilibrium | Loss of balance, not presyncopal |
Neurologic/musculoskeletal
Nonspecific | Ill-defined, not vertiginous or presyncopal | Multiple possible causes
Radiation/Associated Symptoms
Key Associated Symptoms to Query
Vestibular Symptoms (Triad for Vestibular Problems):
- Nausea/vomiting
- Tinnitus (ringing in ears) - Hearing loss
Neurologic Red Flags (Suggest Central Cause):
- Diplopia (double vision)
- Dysarthria (slurred speech)
- Dysphagia (difficulty swallowing)
- Truncal ataxia
- Numbness or tingling in extremities
- Weakness
- Headache
- Changes in bowel/bladder function
Cardiovascular Symptoms:
- Palpitations
- Chest pain/pressure
- Shortness of breath- Syncope (actual fainting)
Other Symptoms:
- Vision changes (dims, spots before eyes, curtain coming down)
- Neck pain
- Cough, micturition, defecation-associated symptoms
- Anxiety, tingling in fingers or around mouth
Severity
- Interference with activities of daily living
- Impact on work/occupation
- Ability to go out independently
- Falls due to dizziness
- Numeric Rating Scale: 0-10 (0 = no dizziness, 10 = worst imaginable)
Timing
- Pattern: Acute vs. chronic; constant vs. intermittent- Onset: Sudden vs. gradual - Duration of each episode:
- Seconds (<1 min) BPPV
- Minutes to hours Vestibular migraine, Meniere's
- Days Vestibular neuritis
- Frequency: How often episodes occur
- Total time symptom present: Days, weeks, months
SUBJECTIVE ASSESSMENT - REVIEW OF SYSTEMS (ROS)
General
- Fever/chills
- Weight loss/gain
- Fatigue
- Night sweats
- Patient Report: Denies neck stiffness, hearing loss initially; may report blurry vision
HEENT (Head, Eyes, Ears, Nose, Throat)
Head:
- Headaches (patient may report headaches) - Head trauma
Eyes:
- Blurry vision (patient may report)
- Double vision (diplopia) - important red flag
- Visual loss
- Eye pain- Changes in vision
Ears:
- Hearing loss (denies in some cases)
- Tinnitus (ringing)
- Ear fullness/pressure
- Ear pain- Otalgia
Nose:
- Sneezing (denies)
- Cough (denies)
- Runny nose (denies) - Congestion
Throat:
- Sore throat (denies)
- Difficulty swallowing
Cardiovascular
- Chest pain (denies)
- Heart palpitations (denies)
- Edema (denies)
- Orthopnea
- Paroxysmal nocturnal dyspnea
Respiratory
- Shortness of breath (denies)
- Cough (denies)
- Weight loss (denies)
Gastrointestinal
- Nausea (may report)
- Vomiting (may report)
- Diarrhea (denies)
- Abdominal pain (denies)
Genitourinary
- Burning upon urination (denies)
- Pregnancy (denies) - Frequency/urgency
Musculoskeletal
- Muscle aches/pains (denies)
- Back pain (denies)
- Joint pain (denies)
- Stiffness (denies) - Recent trauma
Neurologic
- Headaches (may report)
- Dizziness/vertigo (PRIMARY COMPLAINT)
- Syncope (may deny)
- Numbness/tingling in extremities (may deny)
- Weakness
- Coordination problems
- Change in bowel/bladder function (denies)
Integumentary/Breast
- Skin changes (denies)
- Breast changes (denies)
- Rashes
Psychiatric
- Anxiety (may deny)
- Depression (may deny)
- Stress
- Sleep disturbances
Endocrine
- Sweating (denies)
- Cold intolerance (denies)
- Heat intolerance (denies)
Hematologic/Lymphatic
- Enlarged lymph nodes (denies) - Easy bruising/bleeding
Allergic/Immunologic
- Asthma (denies)
- Hives (denies)
- Eczema (denies)
- Allergies (document specifically)
SUBJECTIVE ASSESSMENT - PAST MEDICAL/SOCIAL/FAMILY HISTORY
Past Medical History (PMH)
Chronic Conditions to Document
- Hypertension (high blood pressure) - important vascular risk factor
- Diabetes mellitus
- Hyperlipidemia/dyslipidemia - vascular risk factor
- Cardiovascular disease - coronary artery disease
- Cerebrovascular disease - TIA, stroke history
- Thyroid disease (hypothyroidism) - vascular risk factor
- Migraine history - vestibular migraine risk
- Ear disorders (Meniere's, previous vertigo)
- Cervical arthritis - can contribute to dizziness
- Anxiety/depression
Previous Hospitalizations/Surgeries
- Document all hospitalizations with dates and reasons
- Document all surgeries with dates- Note: Some cases report "None"
Medications (Current and Recent)
Critical for Dizziness Evaluation
Medication Classes That Can Cause Dizziness
1. Antihypertensives - cause orthostatic hypotension
2. Diuretics - dehydration, electrolyte imbalance
3. Antibiotics - especially aminoglycosides (ototoxic)
4. NSAIDs
5. Antiepileptics - sedation, ataxia
6. Antidepressants - orthostatic hypotension, sedation
7. Benzodiazepines - sedation, ataxia
8. Antihistamines - sedation
9. Sedatives/hypnotics
Recent Medication Changes
- New medications started
- Dose changes
- Medications stopped (including birth control)
Allergies
- Drug allergies with reactions
- Food allergies
- Environmental allergies
- Note: Some cases report "None"
Social History
Occupation and Functional Status
- Patient may be: Graduate student working part-time- Occupation affected by dizziness?
- Ability to perform activities of daily living (ADLs)
- Driving status (safety concern with dizziness)
Lifestyle Factors
- Alcohol use: Amount and frequency
- Caffeine intake: Amount and frequency
- Tobacco use: Current/former/never, pack-years
- Recreational drug use
Sexual History
- Sexually active?
- Birth control use (may have stopped)
- Pregnancy status (if applicable)
Living Situation
- Lives alone or with others
- Home environment (stairs, fall hazards)
- Support system
Patient's Concerns
- "What are your concerns about this dizziness?"- Fear of stroke?
- Fear of falling?
- Impact on daily life?
Family History
Relevant Family History to Document
- Ear or hearing problems
- Migraine history (vestibular migraine)
- Cardiovascular disease
- Stroke/TIA
- Autoimmune disorders
- Note: Patient may not know about birth father; mother may have headaches
OBJECTIVE ASSESSMENT - VITAL SIGNS AND GENERAL APPEARANCE
Vital Signs (Critical for Dizziness Evaluation)
Standard Vital Signs
Parameter | Normal Range | Clinical Significance
Blood Pressure | 120/80 mmHg | Orthostatic changes critical
Heart Rate | 60-100 bpm | Arrhythmias can cause dizziness
Respiratory Rate | 12-20/min | Tachypnea may indicate anxiety
Temperature | 97.8-99.1F | Fever suggests infection
O2 Saturation | 95% on room air | Hypoxia can cause dizziness
ORTHOSTATIC BLOOD PRESSURE
ESSENTIAL FOR DIZZINESS
Definition of Orthostatic Hypotension:
- Systolic BP decrease 20 mmHg OR
- Diastolic BP decrease 10 mmHg
- Measured from sitting/supine to standing
Measurement Protocol
1. Patient supine for 5 minutes
2. Measure BP and pulse
3. Patient stands
4. Measure BP and pulse at 1 minute and 3 minutes
5. Delayed orthostatic hypotension: May require tilt-table testing
Clinical Significance
- Common cause of presyncope/lightheadedness
- More common in older adults (patient is 68)
- Can be medication-induced
- May indicate autonomic dysfunction
General Appearance Documentation Elements
Finding | Normal | Abnormal
Alertness | Alert and oriented | Confused, lethargic
Distress | Not in distress | In acute distress
Appearance | Calm, appropriate | Anxious, agitated
Orientation | Awake, Alert, Oriented x3 | Disoriented
Trauma signs | None | Evidence of falls
Key Observations
- Patient appears calm, alert, and oriented
- Evidence of trauma if patient has fallen
- Signs of acute distress
- Ability to maintain balance while sitting
OBJECTIVE ASSESSMENT - FOCUSED PHYSICAL EXAMINATION
HEENT Examination
Head
- Normal: Normocephalic, atraumatic
- Abnormal: Trauma signs, masses
Eyes
Test | Normal Finding | Abnormal Finding
Pupils | Reactive and equal, PERRLA | Unequal, non-reactive
Visual fields | Full to confrontation | Deficits suggest CNS lesion
Extraocular movements | Smooth, full range | Nystagmus, limitation
Conjunctiva | Pink, moist | Pale (anemia), injected
Ears
CRITICAL FOR VESTIBULAR ASSESSMENT
- Hearing test: Whisper test or tuning fork (Weber/Rinne)
- Pinna: No tenderness, masses
- Canal: Clean, no discharge
- Tympanic membrane: Pearly gray, intact, normal landmarks
- Hearing loss: If vertigo present, test hearing
- Note: Patient may deny hearing loss
Nose and Throat
- Normal: No abnormalities
- Note: Patient may deny sneezing, cough, runny nose, sore throat
Neck
- Range of motion: Without restrictions
- Cervical arthritis: Can contribute to dizziness
- Carotid bruits: Consider auscultation gently, especially in older patient- Lymph nodes: No enlarged nodes
Cardiovascular Examination Elements
- Inspection: PMI visible?- Auscultation:
- No murmurs
- No cyanosis
- No clubbing
- Edema: No edema
- Rhythm: Regular vs. irregular (arrhythmia check)
Clinical Significance
- Arrhythmias can cause presyncope/dizziness
- Murmurs may indicate structural heart disease
- Important for ruling out cardiovascular causes
Respiratory Examination
Elements
- Chest expansion: Symmetric
- Auscultation: Lungs clear, no wheezes/rales/crackles
- Note: Patient may deny shortness of breath, cough, weight loss
Abdominal Examination
Elements
- Inspection: Symmetrical, no distention
- Auscultation: Bowel sounds normal
- Palpation: Soft, non-tender, no masses
- Note: Patient may deny abdominal pain, diarrhea
OBJECTIVE ASSESSMENT - NEUROLOGICAL AND VESTIBULAR EXAM
Complete Neurological Examination
Mental Status
- Alert and Oriented
- Orientation x3 (person, place, time)
- Attention and concentration
- Memory (recent and remote)
Cranial Nerves (CN I-XII)
CN II | Optic | Visual acuity, fields | Visual causes of dizziness
CN III, IV, VI | Oculomotor, Trochlear, Abducens | EOM, pupillary response
CN V | Trigeminal | Facial sensation, mastication | Sensory deficits
CN VII | Facial | Facial movement | Facial weakness
CN VIII | Vestibulocochlear | Hearing and balance | CRITICAL FOR DIZZINESS CN IX, X | Glossopharyngeal, Vagus | Swallowing, gag | Dysphagia (central red flags)
Motor Examination
- Strength: 5/5 in all extremities (or document deficits)
- Note: Patient may deny muscle aches, weakness
- Proximal vs. distal strength
- Side-to-side comparison
Sensory Examination
- Light touch: Intact
- Pain/temperature: Intact
- Proprioception: Important for balance
- Vibration: Important for balance
- Note: Patient may deny numbness/tingling
Reflexes
- Deep tendon reflexes: 2+ and symmetric (biceps, triceps, brachioradialis, patellar)
- Babinski: Downgoing (negative) - upgoing suggests CNS lesion
Cerebellar Function
CRITICAL FOR DIZZINESS
Test | Method | Normal | Abnormal
Finger-to-nose | Touch finger to nose, then examiner's finger | Smooth, accurate
Heel-to-shin | Heel down shin to knee | Smooth | Ataxia, inability
Rapid alternating movements | Pronate/supinate hands | Smooth, rapid |
Dysdiadochokinesia
Romberg test | Stand feet together, eyes closed | Stable | Positive = loss of balance
Gait | Walk normally, heel-to-toe | Stable, normal base | Wide-based gait
Romberg Test Interpretation
- Positive Romberg: Patient loses balance or falls when eyes closed
- Indicates: Bilateral vestibulopathy or somatosensory dysfunction
- Not positive: If patient falls with eyes OPEN (cerebellar problem)
Vestibular-Specific Examination
Dix-Hallpike Maneuver
DIAGNOSTIC FOR BPPV
Purpose: Identify benign paroxysmal positional vertigo (BPPV)
Technique
1. Patient begins in sitting position
2. Head turned 45 to one side
3. Examiner holds back of head
4. Gently lower patient to supine position
5. Head extended backward 20 (hangs slightly off table)
6. Observe for nystagmus for 30 seconds
7. Raise patient to sitting position
8. Wait 1 minute rest
9. Repeat on other side
Positive Test
- Patient reports: Reproduction of vertigo
- Clinician observes: Nystagmus (involuntary eye movement) - BPPV nystagmus characteristics:
- Fast component towards affected side
- Fatigable (decreases with repetition)
- Torsional and vertical nystagmus towards affected ear
- Appears within seconds of position change
- Lasts <10 seconds typically
Diagnostic Criteria for BPPV
- Episodes of vertigo/dizziness triggered by position change
- Attacks last <1 minute
- Dix-Hallpike produces torsional/vertical nystagmus towards affected ear after few seconds
Atypical Nystagmus (Worry for central etiology)
- Central vertigo nystagmus:
- Not fatigable
- Lasts longer
- Appears immediately
- Direction-changing
- Vertical or pure torsional without fatigability
- Action: Emergent imaging if atypical
HINTS Examination
(Head Impulse, Nystagmus, Test of Skew)
ONLY for patients who are currently symptomatic (acutely vertiginous)
Component | Method | Normal/Negative | Abnormal/Positive
Head Impulse | Rapid small-amplitude (~20) head rotations side-to-side while patient fixates | Normal if no catch-up saccade | Abnormal if catch-up saccade
Nystagmus | Observe eyes in primary gaze | No nystagmus | Directionchanging
Test of Skew | Cover/uncover each eye alternately | No vertical misalignment | Vertical skew deviation
HINTS Exam Interpretation
- Hallmarks of CENTRAL cause (stroke):
- Normal (negative) horizontal head impulse test
- Direction-changing nystagmus
- Positive skew deviation
- Action: Emergent MRI of posterior fossa
- Hallmarks of PERIPHERAL cause (BPPV, vestibular neuritis):
- Abnormal (positive) head impulse test
- Unidirectional nystagmus- Negative skew test
Head Impulse Test
Detailed
Most useful bedside test of peripheral vestibular function
Procedure:
1. Patient fixates on target (examiner's nose)
2. Examiner rotates head rapidly to left (~20)
3. Observe eyes for maintenance of fixation
4. Return to center
5. Repeat to right
Positive Test
- VOR (vestibuloocular reflex) deficient
- Rotation followed by catch-up saccade in opposite direction
- Example: Leftward saccade after rightward rotation
- Indicates peripheral vertigo
Negative Test
- Eyes maintain fixation
- No catch-up saccade
- May indicate central cause if other findings support
Dynamic Visual Acuity Procedure:
- Measure visual acuity at rest
- Measure acuity with head rotated back and forth by examiner
- Drop in acuity >1 line on Snellen chart = vestibular dysfunction
OBJECTIVE ASSESSMENT - OTHER SYSTEMS AND DIAGNOSTIC TESTS
Musculoskeletal Examination
Elements
- Range of motion: Without restrictions
- Strength: Normal throughout
- Joint examination: No pain, swelling
- Back examination: No pain (patient may deny)
- Note: Patient may deny joint pain, stiffness, back pain
Integumentary Examination
Elements
- Skin: No redness or abnormalities
- Temperature: Warm, dry
- Turgor: Normal (dehydration check)
- Note: Patient may deny skin changes
Lymphatic Examination
Elements
- Nodes: No enlarged nodes
- Areas: Cervical, axillary, inguinal
- Note: Patient may deny enlarged nodes
Genitourinary/Rectal
Note: Exam may not be performed for this case
Diagnostic Testing
Point-of-Care Tests (All Dizzy Patients)
Test | Rationale
Glucose | Hypoglycemia can be deadly; must rule out
EKG | Arrhythmias can be deadly; must rule out
Laboratory Tests (When Indicated)
Basic Labs
- Complete Blood Count (CBC): Anemia, infection
- Basic Metabolic Panel (BMP): Electrolytes, renal function, glucose
- Thyroid Function Tests (TSH): Hypothyroidism is vascular risk factor
- Vitamin B12: Deficiency can cause neurologic symptoms
Specialized Labs (When Specific Diagnosis Suspected)
- Autoimmune panel: If autoimmune vestibular disorder suspected
- VDRL/RPR: If neurosyphilis suspected (rare)
- Audiometry: If hearing loss present (Meniere's evaluation)
Imaging Studies
When to Image (Central Cause Suspected) Indications for Imaging:
- HINTS exam suggests central cause
- Atypical nystagmus on Dix-Hallpike
- Other neurologic abnormalities
- Vascular risk factors present
- About 10% of strokes present with vertigo as only symptom
Imaging Modalities
Modality | Indication | What It Shows
Non-contrast Head CT | Emergency rule-out hemorrhage | Acute hemorrhage, mass
CTA Head/Neck | Vascular evaluation | Vascular dissection, stenosis
MRI Head | Initial test for central vertigo | Posterior fossa stroke
MRI Posterior Fossa | Specific for central vertigo | Brainstem
Temporal Bone CT (high-resolution) | Superior canal dehiscence | Bony
Carotid Doppler Ultrasound | Stroke workup | Carotid stenosis
When Imaging is NOT Necessary
- Classic BPPV with positive Dix-Hallpike
- Typical peripheral vestibular symptoms
- No red flags
- Normal HINTS exam (if acute vertigo)
Cardiac Evaluation (When Cardiovascular Cause Suspected) Echocardiogram with Bubble Study
- Indication: Stroke workup, cardiovascular etiology
- Shows: Patent foramen ovale (PFO), embolic source
Cardiac Monitoring
- Indication: Arrhythmia suspected
- Options: Holter monitor, event monitor, telemetry
ASSESSMENT - DIFFERENTIAL DIAGNOSIS
Systematic Approach to Differential Diagnosis
Dizziness differential is broad due to varied sensations and causes.
Classification by Sensation Type
Sensation Type | Primary Etiologies
Vertigo | Peripheral vestibular (BPPV, vestibular neuritis, Meniere's) or central
Presyncope | Cardiovascular (arrhythmia, orthostatic hypotension)
Disequilibrium | Neurologic, musculoskeletal, bilateral vestibulopathy
Nonspecific | Medication-induced, anxiety, multiple factors
Classification by Anatomic Location
Category | Causes
Central/Neurologic | Cerebellar/brainstem stroke, posterior circulation TIA
Peripheral/Vestibular | BPPV, vestibular schwannoma, vestibular migraine, Meniere's
Cardiovascular | Orthostatic hypotension, presyncope, vertebral artery dissection
Top Differential Diagnoses for 68-Year-Old Female with Dizziness
1. BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) - MOST LIKELY FINAL
DIAGNOSIS
Epidemiology: Most common cause of vertigo, especially in older adults
Diagnostic Criteria
Criterion | Description
Trigger | Vertigo/dizziness triggered by position change (lying down, rolling over)
Duration | Attacks last <1 minute
Dix-Hallpike | Produces torsional and vertical nystagmus towards affected ear
Clinical Features
- Episodic vertigo with position changes
- Brief episodes (<1 minute)
- No hearing loss
- No other neurologic symptoms
- Dix-Hallpike positive with characteristic nystagmus
- Nystagmus is fatigable
- Nystagmus fast component towards affected side
Key Differentiators
- Positional trigger
- Short duration (<1 min)
- Positive Dix-Hallpike
- No other neurologic deficits
- No hearing loss
- No tinnitus
Prevalence: Most common vestibular disorder in older adults
2. VESTIBULAR NEURITIS
Diagnostic Criteria
Criterion | Description
Onset | Sudden onset vertigo
Duration | Lasts at least 24 hours (continuous)
Associated | Often accompanied by oscillopsia, nausea, tendency to fall
Cochlear | Absence of cochlear symptoms (no hearing loss)
Neurologic | Absence of associated neurologic symptoms/signs
Clinical Features
- Acute, continuous vertigo (not episodic)
- Lasts days
- Nausea, vomiting common
- No hearing loss (distinguishes from labyrinthitis)
- May follow viral illness (URI) - Positive head impulse test
Key Differentiators from BPPV
- Continuous (not episodic)
- Duration >24 hours (not <1 minute)
- Not position-triggered
- Positive head impulse test
3. VESTIBULAR MIGRAINE
Diagnostic Criteria
Criterion | Description
Episodes | 5 or more episodes of vertigo/dizziness with nausea
Duration | Moderate-severe intensity, 5 minutes to 72 hours
Migraine features | At least 50% of episodes accompanied by unilateral headache, photophobia, phonophobia, or aura History | Current or previous history of migraine
Clinical Features
- Episodic vertigo
- Variable duration (minutes to hours)
- Migraine history often present
- May have headache during episodes
- Photophobia, phonophobia
- Can occur without headache ("acephalgic migraine")
Key Differentiators
- Longer duration than BPPV (minutes-hours vs seconds)
- Migraine history/features
- Negative Dix-Hallpike (typically)
4. MENIERE DISEASE
Diagnostic Criteria
Criterion | Description
Vertigo | 2+ episodes of spontaneous vertigo lasting 30 minutes to 12 hours
Hearing | Low-to-medium frequency sensorineural hearing loss
Associated | Unilateral tinnitus, ear fullness, hearing loss (may fluctuate)
Clinical Features
- Episodic vertigo (30 min - 12 hours)
- Fluctuating hearing loss
- Tinnitus
- Ear fullness/pressure
- Classic triad: Vertigo + Hearing loss + Tinnitus
Key Differentiators
- Hearing loss present (BPPV: no hearing loss)
- Tinnitus present
- Ear fullness
- Longer duration than BPPV
5. ORTHOSTATIC HYPOTENSION
Diagnostic Criteria
Criterion | Description
BP Drop | Systolic 20 mmHg OR Diastolic 10 mmHg drop from sitting/supine to standing
Symptoms | Dizziness/lightheadedness upon standing
Clinical Features
- Lightheadedness/presyncope (not true vertigo)
- Upon standing
- Related to medications (antihypertensives, diuretics)
- More common in older adults
- Dehydration can contribute
Key Differentiators
- Not true vertigo (presyncope)
- Orthostatic vital sign changes
- Upon standing
- Not position-change in general (specific to upright posture)
6. CENTRAL VERTIGO (STROKE/TIA)
Critical to Rule Out
- About 10% of strokes present with vertigo as only symptom
Central Etiologies
- Cerebellar stroke
- Brainstem stroke
- Posterior circulation TIA
- Vertebral artery dissection (>50% report dizziness/vertigo)
Red Flags for Central Cause
Finding | Significance
Normal/negative head impulse | Suggests central
Direction-changing nystagmus | Suggests central
Positive skew deviation | Suggests central
Vertical nystagmus | Suggests central
Other neurologic deficits | Dysarthria, dysphagia, weakness, ataxia Atypical Dix-Hallpike | Not fatigable, immediate, longer duration
HINTS Exam (acute vertigo only):
- All three abnormal = Central until proven otherwise
- Requires emergent MRI
Key Differentiators from BPPV
- Other neurologic deficits
- HINTS exam abnormal
- Atypical nystagmus
- Vascular risk factors (HTN, DM, hyperlipidemia, prior stroke)
7. VESTIBULAR LABYRINTHITIS
Diagnostic Criteria
Criterion | Description
Vestibular | Vestibular neuritis symptoms
Cochlear | Plus hearing loss
Trigger | Often after viral illness (URI, otitis media)
Key Differentiator from Vestibular Neuritis
- Hearing loss present (neuritis: no hearing loss)
8. PERSISTENT POSTURAL-PERCEPTUAL DIZZINESS (PPPD)
Diagnostic Criteria
Criterion | Description
Duration | Dizziness/vertigo/unsteadiness present 15/30 days for 3+ months
Pattern | Hours, wax and wane, worse as day progresses
Triggers | Upright posture, motion, moving visual stimuli, complex visual patterns
Impact | Significant functional impairment and distress
Key Differentiators
- Chronic (3+ months)
- Not episodic
- Worse with upright posture and visual stimuli
9. OTHER DIFFERENTIALS
Diagnosis | Key Features
Superior Canal Dehiscence | Bone conduction hyperacusis, sound/pressure
Bilateral Vestibulopathy | Disequilibrium, oscillopsia walking, worse
Perilymphatic Fistula | Hearing loss/tinnitus/dizziness after barotrauma
Vestibular Schwannoma | Progressive hearing loss, tinnitus, imbalance Medication-induced | Review medication list (antihypertensives, antibiotics)
Anxiety/Panic | Hyperventilation, tingling around mouth/fingers
FINAL DIAGNOSIS AND CLINICAL REASONING
Final Diagnosis
Benign Paroxysmal Positional Vertigo (BPPV)
Laterality: [Right/Left] posterior canal (determined by Dix-Hallpike findings)
Rationale for Final Diagnosis Supporting Evidence for BPPV:
Criterion | Patient Presentation
Age | 68 years old - typical demographic
Symptom type | Vertigo (spinning sensation)
Trigger | Position changes (lying down, rolling over)
Duration | Episodes <1 minute
Dix-Hallpike | Positive with torsional/vertical nystagmus
Nystagmus | Fatigable, towards affected side
Hearing | No hearing loss
Tinnitus | Absent
Other neurologic | No other deficits
Why NOT Other Diagnoses?
Alternative Diagnosis | Why Excluded
Vestibular Neuritis | Episodes brief (<1 min), not continuous >24 hours
Meniere's Disease | No hearing loss, no tinnitus, episodes too brief
Vestibular Migraine | No migraine history/features, episodes too brief
Orthostatic Hypotension | Dix-Hallpike positive, true vertigo not presyncope Central Vertigo (Stroke) | HINTS exam negative for central signs, atypical nystagmus
PPPD | Episodic, not chronic 3+ months
Epidemiology and Pathophysiology
Epidemiology of BPPV
Statistic | Value
Prevalence | Most common cause of vertigo
Age | Incidence increases with age
Gender | Affects females up to 3x more than males
BPPV specifically | 20-30% of adults over 60
Pathophysiology of BPPV Mechanism:
- Otoconia (calcium carbonate crystals) dislodge from utricle
- Enter semicircular canal (most commonly posterior canal)
- With head position change, crystals move within canal
- Abnormal endolymph flow stimulates cupula
- False sensation of spinning (vertigo) - Characteristic nystagmus observed
Types:
- Canalithiasis: Crystals free-floating in canal (most common)
- Cupulolithiasis: Crystals adhered to cupula
MANAGEMENT PLAN
Treatment of BPPV
1. CANALITH REPOSITIONING MANEUVERS - FIRST LINE TREATMENT
Epley Maneuver (for posterior canal BPPV) - TREATMENT OF CHOICE
Epley Maneuver Technique (Right Ear)
Step | Position | Duration
1 | Sit on bed, legs stretched. Turn head 45 RIGHT | -
2 | Lie down quickly with head turned 45 RIGHT, tipped back slightly | Wait until dizziness stops
3 | Turn head 45 LEFT (keep back of head on bed) | Wait 30 seconds4 | Roll onto LEFT side, nose pointed down 45 toward floor | Wait until dizziness stops
5 | Return to sitting at edge of bed, head level | Sit for 15 minutes
Epley Maneuver Technique (Left Ear)
Step | Position | Duration
1 | Sit on bed, legs stretched. Turn head 45 LEFT | -
2 | Lie down quickly with head turned 45 LEFT, tipped back slightly | Wait until dizziness stops
3 | Turn head 45 RIGHT (keep back of head on bed) | Wait 30 seconds4 | Roll onto RIGHT side, nose pointed down 45 toward floor | Wait until dizziness stops
5 | Return to sitting at edge of bed, head level | Sit for 15 minutes
Post-Maneuver Instructions
- Keep head upright for next few hours
- Avoid bending over at waist
- Avoid tipping head up or down
- Avoid lying down flat to rest/nap
- Can sleep in normal position at night
- Can continue normal activities next day
- Can do exercise 1-3 times per day
- Stop when positional dizziness stops
- Important: Never do Epley for both ears within same 24-hour period
- Best done once every morning until dizziness resolves
- Efficacy: 80-90% cure rate after 1-3 maneuvers
2. MEDICATIONS
Role: Symptomatic relief only, not curative
Medication | Class | Dose | Purpose
Meclizine | Antihistamine | 25-50 mg PO q6-8h | Vestibular suppressant Dimenhydrinate | Antihistamine | 50-100 mg PO q4-6h | Vestibular suppressant
Promethazine | Antidopaminergic | 12.5-25 mg PO/PR q4-6h | Antiemetic, vestibular suppressant
Benzodiazepines (e.g., diazepam) | Benzodiazepine | Low dose | Vestibular suppressant
Important Considerations:
- Avoid long-term use - can delay vestibular compensation
- Sedation - fall risk, especially in older adults (68-year-old patient)
- Not curative - canalith repositioning is definitive treatment
- Use for acute symptom control only
3. VESTIBULAR REHABILITATION
Indications:
- Persistent symptoms after canalith repositioning
- Recurrent BPPV
- Residual imbalance after vertigo resolves- Bilateral involvement
Components:
- Customized exercise program
- Gaze stabilization exercises
- Balance training
- Habituation exercises
- Performed by vestibular physical therapist
- Efficacy: Helpful for residual symptoms and fall prevention
4. SURGICAL INTERVENTION (Rare)
Indications:
- Refractory BPPV (very rare)
- Recurrent BPPV despite multiple treatments
Options:
- Posterior canal occlusion
- Singular neurectomy
Note: Not indicated for typical BPPV
Follow-Up Plan
When to Follow Up
Scenario | Follow-Up Timing
Successful treatment | Follow-up in 2 weeks for reassessment
Persistent symptoms | Return sooner (within 1 week)
Recurrence | Return as needed
What to Assess at Follow-Up
Assessment | Purpose
Symptom resolution | Confirm treatment success
Repeat Dix-Hallpike | Confirm negative test
Residual imbalance | Determine need for vestibular rehab
Recurrence | Early detection
Medication side effects | Safety monitoring
When to Return Sooner
Patient should return immediately if:
Symptom | Concern
New neurologic symptoms | Stroke (weakness, numbness, dysarthria, visual change)
Severe headache | Stroke, hemorrhage
Chest pain/palpitations | Cardiac cause
Hearing loss | Meniere's, other pathology
Continuous vertigo | Vestibular neuritis, stroke
Inability to walk | Central cause
Falls | Injury risk
Intractable vomiting | Dehydration
Diagnostic Tests to Consider
If Diagnosis Uncertain
Test | Indication
Audiometry | If hearing loss suspected (Meniere's)
MRI Head | If central cause suspected (abnormal HINTS, atypical nystagmus)
Vestibular function tests | VNG (videonystagmography) if uncertain diagnosis
If Diagnosis Confirmed as BPPV
No additional testing needed - diagnosis is clinical
PATIENT EDUCATION
Understanding BPPV
BPPV stands for Benign Paroxysmal Positional Vertigo.
Benign means not dangerous, not life-threatening.
Paroxysmal means comes in sudden episodes.
Positional means triggered by head/body position changes. Vertigo means spinning sensation.
What's Happening
- Tiny calcium crystals in your inner ear have become dislodged
- They've moved into a semicircular canal where they don't belong- When you move your head, these crystals move and send false signals to your brain
- Your brain thinks you're spinning when you're not- This causes the spinning sensation (vertigo)
Is BPPV Dangerous?
Reassurance Points:
- Benign = not dangerous, not life-threatening
- Not a stroke
- Not a tumor
- Not permanent - treatable
- Common - most common cause of vertigo
- Treatable - high success rate with maneuvers
SAFETY PRECAUTIONS AND FALL PREVENTION
Immediate Safety Measures
Fall Risk is Significantly Increased
- Dizziness and difficulty with balance are closely linked with greater fall risk
- Older individuals (patient is 68) more commonly suffer from dizziness
- Older individuals more likely to suffer severe injuries from falls
- Single fall can result in disabling injury that forever changes life
- Dizziness may impair ability to function independently and perform ADLs
Specific Safety Recommendations
Activity | Recommendation | Rationale
Driving | DO NOT DRIVE until symptoms resolved | Safety of patient and others
Walking | Use assistance if unsteady | Fall prevention
Bathing | Use shower chair, grab bars | Slip/fall prevention
Sleeping | Elevate head with extra pillows | May reduce nighttime symptoms
Bending | Avoid bending at waist | Avoid triggering vertigo
Looking up | Avoid looking up suddenly | Avoid triggering vertigo
Getting out of bed | Move slowly, sit first | Prevent orthostatic symptoms
Home hazards | Remove loose rugs, clutter | Fall prevention
Lighting | Ensure good lighting, night lights | Fall prevention
When Symptoms Occur What to Do:
1. Sit or lie down immediately to prevent falling
2. Stay still until vertigo passes
3. Focus on stationary object if possible
4. Call for help if needed
5. Do not try to push through dizziness
Medication Education (If Prescribed)
Meclizine (Antivert) - If Prescribed
Purpose: Helps control nausea and dizziness symptoms temporarily Dosing: 25-50 mg by mouth every 6-8 hours as needed
Important Points:
- Not curative - only controls symptoms
- Drowsiness is common side effect
- Do not drive while taking (additive sedation with dizziness)
- Avoid alcohol (increased sedation)
- Use short-term only (a few days)
- Don't rely on medications - get the Epley maneuver
Side Effects:
- Drowsiness (most common)
- Dry mouth
- Blurred vision- Constipation
When to Take:
- For severe symptoms
- Before activities that might trigger vertigo
- At bedtime if symptoms worse at night
Treatment Education
Epley Maneuver Education
What to Expect:
- You'll feel dizzy during the maneuver (this is expected)
- Each position is held until dizziness stops + 30 seconds
- Whole process takes about 15-20 minutes
- You may feel better immediately or over next few days- May need to repeat 1-3 times for complete resolution
Home Exercises:
- Can perform Epley maneuver 1-3 times daily at home
- Best done in the morning (crystals settle overnight)
- Stop when dizziness resolves
- Don't do both ears in same 24 hours- Normal activities can continue next day
Post-Maneuver Restrictions:
- Keep head upright for few hours
- Don't bend over at waist
- Don't tip head up or down
- Don't lie flat for nap/rest
- Normal sleep position OK at night
Prognosis Education
Expected Course
Aspect | Expectation
Treatment success | 80-90% cured after 1-3 maneuvers
Symptom resolution | May be immediate or over several days
Recurrence | 20-30% recurrence within 1 year
Long-term outlook | Excellent - benign condition
Chronic issues | Rare; may need vestibular rehab if persistent
SOAP NOTE DOCUMENTATION
S - SUBJECTIVE
Medications: [List current medications, note any recent changes]
Allergies: [NKDA or list allergies]
Social History: [Occupation, alcohol use, living situation]
Family History: [Relevant family history]
O - OBJECTIVE Vital Signs:
- BP: [___/___] mmHg (supine), [___/___] mmHg (standing) - Orthostatics:
[Negative/Positive]
- HR: [___] bpm, regular
- RR: [___] /min- Temp: [___]F
- O2 Sat: [___]% RA
General: Alert, calm, oriented x3. No acute distress.
HEENT:
- Head: Normocephalic, atraumatic
- Eyes: PERRLA. Extraocular movements intact. No nystagmus in primary gaze.
- Ears: Tympanic membranes normal bilaterally. Hearing intact to whisper.- Neck: Supple, no bruits. ROM without restriction.
Cardiovascular: Regular rate and rhythm. No murmurs. No edema.
Neurologic:
- Mental status: Alert and oriented x3
- Cranial nerves II-XII: Intact
- Motor: 5/5 strength throughout
- Sensory: Intact to light touch throughout
- Reflexes: 2+ and symmetric
- Cerebellar: Finger-to-nose intact. Heel-to-shin intact.
- Romberg: [Negative/Positive] - Gait: [Normal/Wide-based/Unsteady]
Vestibular Examination:
- Dix-Hallpike Right: [Negative / Positive - torsional/vertical nystagmus towards right ear]
- Dix-Hallpike Left: [Negative / Positive - torsional/vertical nystagmus towardsleft ear]
- Head Impulse Test: [Negative / Positive - catch-up saccade right/left]
- Nystagmus: [None in primary gaze / Present - describe]
- Test of Skew: [Negative / Positive]
Other Systems: [As examined]
A - ASSESSMENT
68-year-old female with acute episodic vertigo
Differential Diagnosis:
1. Benign Paroxysmal Positional Vertigo (BPPV) - [Most likely/Final diagnosis]
2. Vestibular neuritis
3. Vestibular migraine
4. Meniere disease
5. Orthostatic hypotension6. Central vertigo (stroke/TIA)
Final Diagnosis:
Benign Paroxysmal Positional Vertigo (BPPV), [Right/Left] posterior canal
Rationale:
- Episodes triggered by position changes
- Duration <1 minute
- Dix-Hallpike positive with characteristic nystagmus
- No hearing loss or tinnitus
- No other neurologic deficits
- HINTS exam negative for central signs
ICD-10 Code:
H81.1 (Benign paroxysmal positional vertigo)
P - PLAN
Diagnostic Plan:
- Diagnosis clinical, no additional testing needed for typical BPPV - If atypical features: Consider audiometry, MRI
Treatment Plan:
1. Epley Maneuver performed in office today [Right/Left]
- Patient tolerated procedure well - [Significant improvement / Some improvement / No improvement] 2. Home Epley Maneuver:
- Perform 1-3 times daily until symptoms resolve
- Best done in morning
- Stop when symptoms resolve
- Never both ears in 24 hours
3. Medications (if prescribed):
- Meclizine 25 mg PO q6-8h PRN nausea/dizziness
- Use short-term only- Warning about sedation
Patient Education:
- BPPV explained in understandable terms
- Benign, treatable condition
- Not stroke, not dangerous
- Fall risk discussed
- Safety precautions provided
- Warning signs reviewed- Treatment expectations discussed
Safety Counseling:
- Fall risk emphasized (especially important at age 68)
- Do not drive until symptoms resolved
- Use assistance when walking if unsteady
- Shower safety measures
- Home hazard removal
- When to call for help during episodes
Follow-Up:
- Return in 2 weeks for reassessment
- Sooner if: persistent symptoms, worsening, red flag symptoms- Red flags reviewed (stroke symptoms, hearing loss, continuous vertigo, chest pain)
Referrals:
- Vestibular physical therapy if persistent symptoms- ENT if recurrent or atypical
Contingency Planning:
- If no improvement after 3 home maneuvers: Return sooner
- If recurrence: Same treatment can be repeated
CLINICAL GUIDELINES AND EVIDENCE BASE
Evidence-Based Guidelines for Dizziness/BPPV
American Academy of Otolaryngology-Head and Neck Surgery Foundation
(AAO-HNSF)
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo Key Recommendations:
Recommendation | Strength
Clinicians should distinguish BPPV from other causes of vertigo | Strong
Clinicians should perform Dix-Hallpike to diagnose BPPV | Strong
Clinicians should treat BPPV with canalith repositioning (Epley) | Strong
Clinicians may offer vestibular rehabilitation for persistent symptoms |
Option
Clinicians should assess for fall risk | Strong
Diagnostic Criteria Summary
BPPV Diagnostic Criteria (International Classification of Vestibular Disorders)
Criterion | Requirement
A | Episodes of vertigo/dizziness triggered by position change
B | Attacks last <1 minute
C | Dix-Hallpike produces torsional/vertical nystagmus towards affected ear
D | Not better accounted for by other diagnosis
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