Mock Patient Script – Dizziness / Vertigo

🌀 “The room spins, my body sways, and I can’t trust my own balance.”

Dizziness is a common but complex symptom that spans across multiple specialties—ENT, neurology, cardiology, and psychiatry. For clinicians, the challenge lies in distinguishing between vertigo, presyncope, and disequilibrium, and identifying red flags that may indicate stroke, arrhythmia, or other life-threatening conditions.

Through the following mock patient scripts, we will sharpen our history-taking skills, recognize key physical findings, and develop a structured approach to differential diagnosis and clinical decision-making.



 

🟦 Case 1 – “Every time I turn my head, the room spins.”

🚪 Doorway Information

  • Age / Gender: 68-year-old female
  • Chief Complaint: “Dizzy spells when I turn in bed.”
  • Vital Signs: T 36.8°C, HR 78, BP 132/84, RR 14, SpO₂ 98%

🗣️ Structured History

  • Opening: “When I lie down or turn to my right, everything starts spinning.”
  • Shoreline: The dizziness started 3 days ago. It occurs only when changing head positions, especially when lying down or getting up. It lasts less than a minute.
  • Associated Symptoms: No hearing loss, no tinnitus, no headache, no visual changes, no nausea unless dizzy. No recent infections.
  • Mood / Function / Appetite / Sleep: Slight anxiety about falling. Eating and sleeping are unaffected, but she avoids sudden movements.
  • Medical History / Medication: Hypertension, controlled with amlodipine. No history of vertigo before.
  • Family & Social History (PAM HITS FOSS):
    • Previous & Past medical history: HTN
    • Allergy: NKDA
    • Medication: Amlodipine 5mg
    • Hospitalization / Injury / Trauma / Surgery: None
    • Family history: Non-contributory
    • OBGYN: Postmenopausal
    • Sexual history: Not relevant to current case
    • Social history: Lives with husband, independent ADLs
  • Concerns & Questions: “Is this something serious? I’m scared I might fall.”

🩺 Physical Examination

  • Positive findings: Dix-Hallpike test on right side induces rotary nystagmus and vertigo lasting about 20 seconds.
  • Important negative findings: No spontaneous nystagmus, Romberg negative, normal finger-to-nose and heel-to-shin testing, normal cranial nerves.
  • HEENT: Normal tympanic membranes, no signs of infection.
  • Neuro: Intact strength and sensation. No dysarthria, no ataxia.

🧠 Differential Diagnosis

  • Most likely: Benign Paroxysmal Positional Vertigo (BPPV)
    • Supporting: Triggered by positional changes, brief duration, positive Dix-Hallpike, no central signs
    • Against: None strongly contradictory
  • 2nd: Vestibular neuritis
    • Supporting: Acute vertigo possible
    • Against: No constant symptoms, no preceding viral illness, no gait instability
  • 3rd: Orthostatic hypotension
    • Supporting: Common in elderly
    • Against: No symptoms when standing, dizziness only with head turning

🧩 Clinical Reflection

This seems like a textbook case of BPPV. The triggered, short-lived spinning sensations with a classic Dix-Hallpike response strongly point to it. Still, it’s important to rule out any red flags or central signs.

💡 Clinical Pearls

  • BPPV is the most common cause of vertigo in the elderly.
  • Always differentiate central from peripheral vertigo—do not miss a stroke.
  • Positive Dix-Hallpike = rotational nystagmus + reproduction of vertigo.
  • Epley maneuver can be both diagnostic and therapeutic.
  • Never assume it’s “just BPPV” without a neuro exam.

❓ Challenging Questions

Q: “Is this a sign of a brain tumor?”

A: “I understand why you’d be concerned. Based on what we’ve seen so far, this doesn’t point to a brain tumor. It fits a common inner ear condition. That said, we’ll keep monitoring and perform further tests if needed. You’re not alone in this.”

Q: “Do I need a scan?”

A: “In most cases like yours, imaging isn’t necessary because the cause is clear and benign. However, if symptoms change or don’t improve, we may consider a brain scan just to be safe.”

📝 SOAP Note

S: 68-year-old female with 3-day history of brief spinning dizziness triggered by positional changes. No hearing loss or focal neurological symptoms. 
O: T 36.8°C, HR 78, BP 132/84. Dix-Hallpike test positive on right. Otherwise normal neuro exam.
A: 
# Positional vertigo triggered by lying down/turning  
# Positive positional testing (Dix-Hallpike)  
# No signs of central vertigo  

ddx): BPPV, vestibular neuritis, orthostatic hypotension  
r/o): Central vertigo (no ataxia, no focal neuro findings)  

→ Likely BPPV given typical triggers and exam findings. Will initiate canalith repositioning and observe.

P:
- Epley maneuver in clinic  
- Fall precautions, avoid sudden head movements  
- Follow-up in 1 week or earlier if worsening  
- Patient education and reassurance

 

🟥 Case 2 – “I can’t stop throwing up and my voice sounds strange.”

🚪 Doorway Information

  • Age / Gender: 42-year-old male
  • Chief Complaint: “Sudden severe dizziness and vomiting.”
  • Vital Signs: T 36.9°C, HR 86, BP 148/92, RR 18, SpO₂ 98%

🗣️ Structured History

  • Opening: “I suddenly got dizzy yesterday, and now I can’t stop vomiting.”
  • Shoreline: He developed abrupt onset of severe vertigo, nausea, and imbalance about 24 hours ago. Dizziness is constant and worsens when turning his head.
  • Associated Symptoms: Hoarseness, difficulty swallowing, left-sided facial numbness, right arm tingling. No fever, headache, or visual symptoms.
  • Mood / Function / Appetite / Sleep: Poor oral intake due to nausea. Could not walk without assistance since onset. Anxious but alert.
  • Medical History / Medication: Smoker (20 pack-years), borderline hypertension. No known cerebrovascular disease.
  • Family & Social History (PAM HITS FOSS):
    • Previous & Past medical history: Mild HTN, no prior stroke
    • Allergy: None
    • Medication: None regularly
    • Hospitalization / Injury / Trauma / Surgery: Reported mild neck strain during stretching 2 days ago
    • Family history: Father had early stroke
    • OBGYN: N/A
    • Sexual history: No risk factors reported
    • Social history: Works as a lawyer, frequent desk work, smokes, occasional alcohol
  • Concerns & Questions: “Why is my voice weird? Am I having a stroke?”

🩺 Physical Examination

  • Positive findings:
    • Left-sided ptosis and miosis (Horner’s syndrome)
    • Horizontal nystagmus beating to the right
    • Left facial numbness (CN V), right-sided loss of pain and temperature in limbs
    • Ataxia with left finger-nose and heel-knee-shin testing
    • Hoarseness, weak gag reflex
  • Important negative findings: Normal motor strength, no dysarthria, normal visual fields and eye movements (except nystagmus)

🧠 Differential Diagnosis

  • Most likely: Wallenberg Syndrome (Lateral Medullary Infarction)
    • Supporting: Crossed sensory findings, Horner’s, ataxia, hoarseness, nausea, constant vertigo
    • Against: None significant
  • 2nd: Vestibular Neuritis
    • Supporting: Acute vertigo and nausea
    • Against: No cranial nerve findings, no Horner’s, no crossed sensory deficits
  • 3rd: Cerebellar hemorrhage
    • Supporting: Sudden severe vertigo with ataxia possible
    • Against: No headache, no altered mental status, normal BP

🧩 Clinical Reflection

This case highlights a crucial point: not all vertigo is peripheral. His crossed sensory loss and cranial nerve findings led me to suspect a brainstem stroke. His recent neck manipulation also raised concern for vertebral artery dissection.

💡 Clinical Pearls

  • Vertigo with neurological deficits → think central causes.
  • Crossed findings (ipsilateral face, contralateral body) suggest brainstem lesion.
  • Horner’s syndrome with vertigo = red flag for Wallenberg.
  • Vertebral artery dissection is a common cause of stroke in young adults.
  • Normal head CT does not exclude posterior circulation stroke → MRI is needed.

❓ Challenging Questions

Q: “Is this going to affect me permanently?”

A: “That’s a valid concern. Right now, we’re still in the early phase, and many people recover well with rehabilitation. But some symptoms may take time to improve. We’ll coordinate your care with neurology and monitor your progress closely.”

Q: “Could this happen again?”

A: “There is a risk of recurrence, especially if the underlying cause—like a dissection or high blood pressure—isn’t managed. But we’ll do all the necessary imaging and start treatments to reduce that risk.”

📝 SOAP Note

S: 42-year-old male with sudden onset vertigo, nausea, hoarseness, left facial numbness, right arm tingling, imbalance. Neck strain reported 2 days prior. 
O: T 36.9°C, HR 86, BP 148/92. Left Horner’s, crossed sensory deficits, left-sided ataxia, hoarse voice. No motor weakness. 
A:
# Sudden-onset vertigo with neuro findings  
# Crossed sensory loss, Horner's, CN deficits  
# Hx of minor trauma (neck strain)  

ddx): Wallenberg syndrome, vestibular neuritis, cerebellar stroke/hemorrhage  
r/o): BPPV (not position-dependent, persistent symptoms), labrynthitis (no hearing loss)

→ Wallenberg syndrome highly likely due to lateral medullary infarct, likely from vertebral artery dissection. Urgent imaging warranted.

P:
- Admit for stroke workup  
- MRI brain with diffusion + MRA neck  
- Start antiplatelet therapy  
- Monitor swallowing; consider speech therapy consult  
- Neurology referral  
- BP management, counsel on smoking cessation

 

🟪 Case 3 – “My vision went dark for a second… I thought I was going to pass out.”

🚪 Doorway Information

  • Age / Gender: 31-year-old female
  • Chief Complaint: “Dizzy and lightheaded, especially when standing.”
  • Vital Signs: T 36.5°C, HR 72 (standing: 94), BP 112/76 (standing: 92/60), RR 14, SpO₂ 99%

🗣️ Structured History

  • Opening: “When I stood up to get water, I felt like I was about to faint.”
  • Shoreline: She’s had several brief episodes over the past week, mostly in the morning or after standing up quickly. Lasts less than a minute, then resolves.
  • Associated Symptoms: Blurred vision, lightheadedness, “floating” feeling. No true spinning, no hearing loss, no chest pain or palpitations. One episode involved tingling in fingers and mild hyperventilation.
  • Mood / Function / Appetite / Sleep: Appetite is normal but she’s been skipping meals due to work. Sleep quality is poor due to stress. Increased baseline anxiety recently.
  • Medical History / Medication: No chronic conditions. Occasionally takes OTC sleep aid. No birth control or cardiac meds.
  • Family & Social History (PAM HITS FOSS):
    • Previous & Past medical history: Healthy
    • Allergy: NKDA
    • Medication: Occasional diphenhydramine
    • Hospitalization / Injury / Trauma / Surgery: None
    • Family history: Father has anxiety, no cardiac history
    • OBGYN: Regular menses, not pregnant
    • Sexual history: Active, no recent issues
    • Social history: Works in finance, long hours, high stress. No smoking, drinks occasionally
  • Concerns & Questions: “Is something wrong with my heart? Or am I just stressed?”

🩺 Physical Examination

  • Positive findings:
    • Orthostatic hypotension: BP drops >20 mmHg systolic when standing
    • Mild tachycardia on standing
    • Anxious affect, shallow breathing noted during episode
  • Important negative findings: No nystagmus, no focal neurological deficits, heart sounds normal, no murmurs, clear lungs, capillary refill normal

🧠 Differential Diagnosis

  • Most likely: Orthostatic hypotension (due to dehydration + vasovagal tendency)
    • Supporting: Symptoms on standing, hypotension with HR rise, skipped meals, poor sleep
    • Against: No major volume loss or autonomic disorder signs
  • 2nd: Anxiety-related pre-syncope / hyperventilation syndrome
    • Supporting: Stress, tingling, shallow breathing, no objective abnormalities
    • Against: Real orthostatic changes noted
  • 3rd: Cardiac arrhythmia
    • Supporting: Sudden lightheadedness could suggest this
    • Against: No palpitations, no syncopal episode, normal exam

🧩 Clinical Reflection

This case reminds me how pre-syncope often hides in plain sight. The orthostatic drop is measurable, and her lifestyle factors support the diagnosis. Still, given her anxiety, it’s important to validate her symptoms and rule out cardiac causes if persistent.

💡 Clinical Pearls

  • Always measure orthostatics in dizzy patients—it’s often revealing.
  • Pre-syncope = lightheadedness without complete LOC. Still serious.
  • Dehydration, skipped meals, stress = common but modifiable causes.
  • Hyperventilation syndrome can mimic serious conditions.
  • Low suspicion for cardiac cause doesn’t mean no monitoring if symptoms recur.

❓ Challenging Questions

Q: “Do I need to wear a heart monitor?”

A: “That’s a great question. Based on today’s findings, it seems more likely related to blood pressure and lifestyle. But if symptoms recur or change, we may consider monitoring just to be thorough.”

Q: “Is this all in my head?”

A: “Not at all. What you’re feeling is real. Stress and anxiety can affect the body in powerful ways, but that doesn’t make it imaginary. We’ll work together to rule out any physical causes and support your well-being.”

📝 SOAP Note

S: 31-year-old female with episodes of lightheadedness and near-fainting when standing. No palpitations, chest pain, or true syncope. Stressful work schedule, poor hydration.
O: T 36.5°C, HR 72 → 94 (standing), BP 112/76 → 92/60. No neuro deficits. No murmur or cardiac signs.
A:
# Presyncope with orthostatic hypotension  
# Lifestyle-related dehydration/stress  
# Anxiety may contribute  

ddx): Orthostatic hypotension, hyperventilation syndrome, arrhythmia  
r/o): BPPV (not positional), cardiac syncope (no high-risk features)

→ Likely benign presyncope due to lifestyle and autonomic response. No red flags today, but close follow-up advised.

P:
- Encourage hydration, salt intake, slow positional changes  
- Reassure and educate on anxiety + physical interaction  
- Monitor symptoms; consider Holter only if recurrence  
- Follow-up in 1–2 weeks; sooner if worsening or LOC episodes  
- Consider referral to psych support if anxiety escalates

🧾 Article Summary – Clinical Approach to Dizziness / Vertigo

Dizziness is a multifaceted symptom that spans from benign peripheral conditions like BPPV to dangerous central causes such as brainstem stroke. Clinicians must first differentiate between vertigo (spinning), pre-syncope (lightheadedness), and disequilibrium (imbalance). A focused history including triggers, duration, associated symptoms (hearing loss, headache, neuro deficits), and risk factors (age, vascular history) is key. Physical examination—especially positional testing, cranial nerve assessment, and orthostatic vitals—can offer immediate diagnostic clues.

The three mock cases here offer a range from classic BPPV, to vertebrobasilar stroke (Wallenberg syndrome), to orthostatic presyncope due to dehydration or anxiety. Such structured scripts aim to sharpen diagnostic reasoning in both OSCE and clinical practice.

🧠 VITAMIN CDE-based Differential List for Dizziness

  • Vascular: Vertebral artery dissection, Wallenberg syndrome, cerebellar stroke, vasovagal syncope
  • Infectious / Inflammatory: Vestibular neuritis, labyrinthitis, otitis media
  • Trauma: Post-concussion syndrome, whiplash with vertebral injury
  • Autoimmune: MS, lupus-related vasculitis
  • Metabolic / Electrolyte: Hypoglycemia, hyponatremia, anemia
  • Idiopathic / Psychiatric: Panic attack, anxiety disorder, hyperventilation
  • Neoplastic: Brainstem glioma, cerebellopontine angle tumor
  • Congenital / Degenerative: Parkinson’s disease, cerebellar ataxia
  • Drugs / Toxins: Antihypertensives, benzodiazepines, alcohol, ototoxic drugs
  • Endocrine: Hypothyroidism, adrenal insufficiency

🔗 Related Articles


📚 References

  • BMJ Best Practice – Dizziness and Vertigo
  • UpToDate – Evaluation of the dizzy patient
  • 日本めまい平衡医学会「めまい診療ガイドライン2022」
  • Camilo O. Vertigo and Dizziness: An Evidence-Based Approach. 2020.

🎓 Recommended Resources

  • First Aid for the USMLE Step 2 CS – Patient-centered scripts and physical exam review
  • 「診断力を鍛える99症例」(ダ・ヴィンチのカルテ)– 症候から診断を考える日本語書籍
  • ティアニー先生の臨床推論入門 – 初学者にもおすすめの名著
  • Geeky Medics – OSCE Guides: geekymedics.com

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