Clinical Approach to Dizziness: Type-Based Assessment and Red Flags You Shouldn’t Miss

“I feel dizzy.” This common complaint can hide a wide range of underlying causes — from benign inner ear disorders to life-threatening strokes.
Some patients describe a “spinning” sensation, while others report “floating,” “unsteadiness,” or “feeling faint.” Each description offers a valuable clue.
In this article, we break down dizziness into four clinical types and show you how to approach each one systematically — from history taking to physical exam and test selection.
Whether you’re preparing for the OSCE or seeing real patients in clinic, this guide will help you think clearly and act confidently.

🎯 What You’ll Learn in This Article

• Understand the four clinical types of dizziness and how to distinguish between them
• Learn how to ask the right questions and perform physical exams that matter — for both OSCE and real practice
• Develop clinical reasoning to recognize red flags and decide when tests or referrals are needed

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🩺 Case Introduction: Listen to the Patient’s Words First

👵 Doorway Information

• Age / Sex: 72-year-old female
• Chief Complaint: Dizziness upon getting out of bed
• Vitals: BP 138/74 mmHg, HR 78/min, Temp 36.6°C, SpO₂ 97%

🗣️ What the Patient Says

“This morning, when I tried to get out of bed, the ceiling started spinning and I felt nauseous.
It wasn’t just lightheadedness — it really felt like the room was rotating around me.
I didn’t vomit, but I had to lie back down because I was scared it would happen again if I moved.”

Her description of a “spinning sensation” and “dizziness triggered by movement” gives us a clear clue.
But how should we classify her dizziness? Let’s think it through in the next section.

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🧠 First Impressions & Initial Clinical Approach

When a patient says “I feel dizzy,” the first step is always the same: ask them what kind of dizziness they mean.
In this case, the patient clearly described a spinning sensation — a classic sign of rotatory vertigo.

Next, we need to determine: is this a central or peripheral cause?
In older patients, it’s important to rule out serious conditions such as cerebellar stroke or brainstem infarction (e.g. Wallenberg syndrome).

However, this patient’s symptoms — onset upon getting out of bed, triggered by head movement, and relieved with rest — are all typical of BPPV (Benign Paroxysmal Positional Vertigo).

That said, we can’t let our guard down just yet.
Let’s classify the dizziness, check for red flags, and narrow down our differentials in a structured way.

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🧩 Fact / Problem / Hypothesis

🔎 Fact (What the patient said)

• Dizziness started suddenly upon getting out of bed this morning
• She describes the sensation as “the ceiling spinning” (rotatory vertigo)
• Mild nausea, no vomiting
• Symptoms improve with rest but recur with movement
• No hearing loss or tinnitus (no inner ear symptoms)
• Vital signs are stable (normal SpO₂ and blood pressure)

🧠 Problem (Reframing the symptoms)

Based on the brief duration, clear positional trigger, lack of continuous symptoms, and absence of inner ear symptoms, this is likely a case of transient positional vertigo — not a persistent or central type.

Still, we must carefully assess for central red flags such as vertical nystagmus, focal neurological signs, or persistent symptoms. At this point, none are apparent.

💡 Hypothesis (Differential Diagnosis – VITAMIN CDE)

• ✅ Most likely: BPPV (Benign Paroxysmal Positional Vertigo)
• ⚠️ To rule out: Cerebellar stroke, Wallenberg syndrome (central vertigo)
• 🤔 Consider if context changes:
  • Vestibular neuritis (less likely due to non-persistent symptoms)
  • Drug-induced dizziness (if new medications are involved)
  • Meniere’s disease (less likely due to absence of IES)

🎯 NTK – Need To Know Before Moving On

• How long does each episode of dizziness last?
• Is there a reproducible trigger (e.g., head turning, getting up)?
• What type of nystagmus is present? Horizontal? Vertical?
• Are there any inner ear symptoms (hearing loss, tinnitus)?
• Any changes in medications or medical history?

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📝 Step 1: History Taking for Dizziness

Before diving into physical exams or tests, it’s essential to understand how the patient describes their dizziness.
The key is to classify the dizziness into one of four clinical types based on their words.

🔰 Classify Dizziness into 4 Types

• Vertigo: “The room is spinning” → Think central or peripheral vestibular causes
• Presyncope: “I feel like I might faint” → Consider cardiovascular causes
• Disequilibrium: “I feel off-balance or unsteady on my feet” → Think neurologic or musculoskeletal causes
• Lightheadedness: “I feel floaty or spaced out” → Think anemia, psychogenic causes, or medication effects

🧠 For Vertigo, Ask: Central or Peripheral?

If the dizziness is clearly vertigo, the next step is determining whether it’s central (brainstem/cerebellar) or peripheral (inner ear, vestibular nerve).

• Central: Stroke, tumor, MS → Look for neurological signs, vertical/alternating nystagmus
• Peripheral: BPPV, Meniere’s disease, vestibular neuritis → Often positional, with inner ear symptoms

🔍 Inner Ear Symptoms (IES) Narrow the Differential

• IES present:
  • Meniere’s disease: tinnitus, hearing loss, recurrent attacks
  • Acoustic neuroma: progressive unilateral hearing loss + imbalance
  • Otitis media: associated with ear pain or discharge
• IES absent:
  • BPPV: brief, positional, no hearing symptoms
  • Vestibular neuritis: single prolonged episode, often post-viral

⏳ Duration Helps Narrow the Differential

Duration	Possible Diagnoses
Seconds	BPPV, orthostatic hypotension
Minutes to hours	Meniere’s, TIA, psychogenic
Hours to days	Vestibular neuritis, cerebellar stroke
Recurrent/chronic	Drug-induced, psychiatric, central causes

🗺️ Summary: How to Approach History Taking

• Start by identifying the type of dizziness
• If vertigo, distinguish central vs peripheral
• Ask about IES, duration, and triggers
• Use OPQRST + PAM HITS FOSS to explore further

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🧾 Detailed History Taking: OPQRST + PAM HITS FOSS

🔍 OPQRST – Characterizing the Dizziness Episode

• O – Onset: When did it start? Was it sudden or gradual? Related to movement or posture?
• P – Provocation/Palliation: What triggers it? Head movement? Standing up? Does lying down help?
• Q – Quality: Is it spinning, floating, feeling faint, or just unsteady?
• R – Region/Radiation: Dizziness doesn’t radiate, but associated symptoms (e.g., headache, ear symptoms) are important.
• S – Severity: How much does it interfere with daily activities? Has it caused a fall?
• T – Time course: How long does it last? Does it happen repeatedly? Any pattern or change recently?

📚 PAM HITS FOSS – Exploring Background & Risk Factors

• P – Past medical history: Stroke, hypertension, diabetes, inner ear disease
• A – Allergy: Especially to medications that might cause dizziness
• M – Medications: Antihypertensives, SSRIs, benzodiazepines, anticholinergics, pregabalin
• H – Hospitalization: Any history of neurological disease or cardiac issues?
• I – Injury: Head trauma? Recent fall?
• T – Trauma: Motor vehicle accidents? Whiplash?
• S – Surgery: Especially ENT, neuro, or cardiac surgeries
• F – Family history: Stroke, hearing disorders, arrhythmias
• O – OBGYN: Dizziness during pregnancy may suggest anemia or orthostatic hypotension
• S – Sexual history: Rarely, STDs like syphilis can cause vestibular symptoms
• S – Social history:
  • Smoking: Atherosclerosis, vascular risk
  • Occupation: High-risk jobs (e.g., working at heights or driving)
  • Drugs/Alcohol: Toxic or withdrawal-related dizziness
  • Sleep/Stress: Fatigue-related lightheadedness, anxiety
  • Exercise/Diet: Dehydration, electrolyte imbalance, eating habits

Taking a thorough and structured history like this not only helps narrow your differential diagnoses, but also reassures the patient that their story is heard and understood.

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🩺 Step 2: Physical Examination – Central or Peripheral?

After taking a structured history, it’s time to examine the patient and evaluate your working hypotheses.
The goal is to distinguish between central vs peripheral vertigo, and identify any red flags.

👀 First Impressions (At the Door)

• Gait: Unsteady, wide-based, assisted?
• Facial expression: Anxious, eyes fixed, holding onto furniture?
• Standing or sitting up: Smooth or hesitant?

🧠 Neurological Examination

• Nystagmus: Vertical or direction-changing → suggests central cause
• Romberg test: Swaying with eyes closed → sensory ataxia
• Finger-Nose Test (FNF): Look for decomposition or dysmetria
• Heel-Knee Test (HKT): Assess cerebellar coordination in lower limbs

👁️ Nystagmus – What to Look For and How to Interpret

• Direction:
  • Horizontal: Often seen in peripheral vertigo (e.g., BPPV, vestibular neuritis)
  • Vertical: Suggests central cause (e.g., brainstem or cerebellar lesions)
  • Torsional (rotatory): Often associated with BPPV, especially posterior canal
  • Bidirectional (changing direction depending on gaze): Strongly suggests central pathology
• Spontaneous vs Induced:
  • Spontaneous: Present at rest; more concerning for central vertigo
  • Positional/Induced: Triggered by movement; seen in BPPV
• Fatigability: Peripheral nystagmus often diminishes with repeated testing
• Fixation Suppression: Peripheral nystagmus decreases with visual fixation (use Frenzel goggles)

📝 Charting Nystagmus in English

Use structured descriptions like the following:

• “Spontaneous right-beating horizontal nystagmus observed in primary gaze”
• “Torsional upbeating nystagmus provoked on right Dix–Hallpike maneuver”
• “Direction-changing gaze-evoked nystagmus noted → concerning for central cause”

⚖️ Central vs Peripheral Nystagmus – Key Differences

Feature	Peripheral	Central
Direction	Unidirectional (usually horizontal)	Vertical, bidirectional, or changing
Fixation suppression	Present (nystagmus reduces)	Absent (nystagmus persists)
Fatigability	Yes (decreases with repetition)	No (persistent)
Associated signs	Often none	Neurological deficits (e.g., ataxia, dysarthria)

Identifying the type and characteristics of nystagmus is one of the most powerful tools in differentiating central from peripheral causes of dizziness.

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🧪 HINTS Exam (for Acute Vestibular Syndrome)

• Head Impulse Test: Normal = central, Abnormal = peripheral
• Direction-changing Nystagmus: Present = central
• Test of Skew: Vertical misalignment = central

All 3 findings “normal” = consider stroke until proven otherwise!

👂 Otoscopic and Auditory Exam

• Check for signs of otitis media or cerumen impaction
• Use tuning forks:
  • Weber test: Lateralizes to affected side in conductive loss
  • Rinne test: Negative (bone > air) = conductive hearing loss

📈 Balance and Orthostatic Tests

• Schellong test: Check BP/HR before and after standing
• Tandem gait: Heel-to-toe walking → sensitive to cerebellar or vestibular dysfunction

❤️ Cardiovascular Signs

• Blood pressure: Look for orthostatic hypotension
• Pulse: Bradycardia, tachycardia, or irregularity
• Jugular vein distension (JVD): Right heart failure?
• Heart sounds: Murmurs or arrhythmias

🔍 Additional Signs to Consider

• Skin: Dehydration, anemia, café-au-lait spots
• Fundoscopy: Papilledema, retinal hemorrhage, or abnormal eye movement
• MSS (Musculoskeletal): Neck ROM, cervical tenderness, joint instability

Together, these physical findings help confirm or refute your working diagnosis — and guide the need for further testing.

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🧪 Step 3: Tests and Imaging – Rule Out Red Flags and Confirm Your Diagnosis

By now, you’ve gathered clues from the patient’s story and physical exam.
Step 3 is about confirming your hypothesis — and more importantly, ruling out life-threatening conditions.

🧠 Red Flag? Start Here

• Persistent vertigo + abnormal HINTS + neuro signs: Brainstem/cerebellar stroke → Order brain MRI (DWI)
• Orthostatic symptoms + palpitations or syncopal episodes: → Check ECG, Holter monitor, orthostatic BP
• Severe anemia, dehydration, or metabolic derangement suspected: → Order CBC, electrolytes, BUN/Cr, glucose

🎯 Choose Tests Based on Your Working Diagnosis

• Suspect BPPV:
  • Dix–Hallpike maneuver: If positive, confirms diagnosis
  • Imaging NOT needed unless red flags present
• Suspect Meniere’s or SSNHL:
  • Audiometry: Low-frequency sensorineural loss = Meniere’s
  • Sudden unilateral hearing loss: Rule out retrocochlear pathology
• Suspect otitis media or conductive hearing loss:
  • Otoscopy + Tuning fork tests (Weber & Rinne)
• Suspect arrhythmia or cardiac cause:
  • ECG, orthostatic vitals, BNP; consider echocardiography if indicated

🎧 Audiometry – What It Tells You

• Sensorineural hearing loss: Think Meniere’s, SSNHL, vestibular schwannoma
• Low-frequency loss: Meniere’s disease
• Conductive hearing loss (air-bone gap): Otitis media, wax impaction, ossicle issues

👓 Use Frenzel Goggles When in Doubt

Frenzel goggles suppress fixation and enhance subtle nystagmus in peripheral vertigo.
If no nystagmus is visible but BPPV is suspected, try Frenzel or video-oculography.

🩺 Don’t Forget POCUS

• IVC collapse: May suggest dehydration
• Echo findings: EF, effusion, pulmonary congestion
• Bladder scan: Residual urine in elderly with dizziness?

📋 Bonus: San Francisco Syncope Rule (CHESS)

Use in suspected presyncope or syncope:

• C: History of Congestive heart failure
• H: Hematocrit < 30%
• E: Abnormal ECG
• S: Shortness of breath
• S: Systolic BP < 90 mmHg

Use tests wisely — not all dizziness needs imaging. Your history and physical exam often give you the answer.

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🔁 Case Review: Let’s Apply This to Our Case!

Now that we’ve covered Steps 1 to 3, let’s revisit the opening case and walk through the clinical reasoning step-by-step.

📝 Step 1: History Taking

Doctor: “What brings you in today?”
Patient: “When I tried to get out of bed yesterday morning, the room started spinning. I felt so off that I had to lie back down.”

As we asked more detailed questions, we learned:

• Onset: Sudden, 2 days ago
• Quality: Rotatory vertigo (“spinning”)
• Triggers: Positional – worse with head movement, turning in bed
• Duration: Episodes last < 1 minute
• Associated symptoms: Mild nausea; no hearing loss or tinnitus
• PAM HITS FOSS: No major past history, no new medications, no trauma or systemic red flags

🔎 Fact

• Sudden onset of spinning dizziness triggered by head movement
• Episodes last < 1 minute
• No inner ear symptoms (IES)

🧠 Problem

Acute-onset, brief, positional vertigo without IES — strongly suggests a transient positional peripheral vertigo, likely BPPV.

💡 Hypothesis (VITAMIN CDE)

• V: BPPV, vestibular neuritis
• I: Inner ear inflammation (less likely)
• N: Vestibular schwannoma (unlikely without hearing loss)
• C: Posterior circulation TIA (worth keeping in mind)

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🩺 Step 2: Physical Examination

Our focus here was to rule out central causes and confirm peripheral vertigo.

• General impression: Slight gait imbalance but no focal neuro signs
• MMSE: 30/30, no language or cranial nerve deficits
• Romberg: Positive with eyes closed; Fukuda step test → veering

🧪 HINTS Exam

• Head Impulse: Positive → supports peripheral
• Nystagmus: Horizontal, unidirectional → peripheral
• Test of Skew: Negative → central lesion unlikely

✅ Dix–Hallpike Maneuver

• Performed with right ear down → triggered torsional, upbeating nystagmus
• Latency ~10 sec, fatigue in ~30 sec → classic for right posterior canal BPPV

🔍 Additional Tests

• FNF and HKT: Normal
• Weber: Midline; Rinne: AC > BC bilaterally
• Otoscopy: Normal

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🧪 Step 3: Focused Testing

At this point, we were confident in our working diagnosis of BPPV. Here’s what we did:

• Blood tests: CBC, electrolytes → all normal
• Audiometry: Normal bilateral thresholds → rules out Meniere’s & SSNHL
• ECG: Normal sinus rhythm → Presyncope unlikely
• Imaging: Not performed — no red flags or central signs on exam

Conclusion: This is a classic case of right posterior canal BPPV. We proceeded with an Epley maneuver, and the patient felt immediate improvement.

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🧑‍⚕️ When to Refer to Specialists & Outpatient Management

📌 When to Refer to Neurology or ENT

• Red flags on exam: Vertical or bidirectional nystagmus, neurological deficits, positive Test of Skew → Refer to Neurology
• Persistent vertigo despite treatment: If BPPV symptoms don’t improve after 1–2 attempts of Epley maneuver → Consider ENT or vestibular rehab
• Hearing loss or tinnitus: Sudden sensorineural loss, fluctuating hearing → Refer to ENT for audiometry and possible steroids
• Recurrent unexplained dizziness: Especially with syncope or arrhythmia → Refer to Cardiology or consider Holter ECG
• Structural abnormalities suspected: Vestibular schwannoma, tumor → ENT + imaging (MRI with contrast)

🛠️ What to Do Before Referring

• Reassess the basics: Confirm proper performance of Dix–Hallpike and Epley maneuvers.
• Document findings clearly: Note nystagmus type, latency, duration, and response to repositioning.
• Repeat once if necessary: If the first Epley maneuver partially relieves symptoms, try a second attempt.
• Provide home exercises: Teach Brandt-Daroff exercises for patients who can’t access specialist care immediately.
• Safety check: Ensure patient avoids provoking head positions and has safe environment at home (e.g., assistance during maneuvers).
• Monitor progress: If no improvement or worsening after 1–2 tries, consider referral.

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🩺 What You Can Do in Outpatient Settings

• BPPV:
  • Perform Dix–Hallpike for diagnosis and Epley maneuver for treatment
  • Educate patients on avoiding provocative head positions for 24–48 hours
  • Instruct in home-based Brandt-Daroff exercises for recurrence
• Vestibular neuritis:
  • Symptomatic control with antihistamines (e.g., meclizine) or antiemetics
  • Encourage early mobilization and consider referral for vestibular rehab if needed
• Orthostatic dizziness:
  • Check for dehydration, advise on fluid/salt intake, gradual positional changes
  • Review medications that may contribute (e.g., antihypertensives)
• Anxiety-related or functional dizziness:
  • Provide reassurance, rule out serious causes first
  • Consider short-term behavioral support or psychiatric referral if recurrent

  📹 Dix–Hallpike & Epley Resources

  Here are professional videos and diagrams to help visualize these maneuvers:

  • Dix–Hallpike Maneuver (OSCE demo):
    YouTube – OSCEskills
  • Dix–Hallpike for BPPV diagnosis:
    YouTube – Dr. Michael Teixido
  • Epley Maneuver diagram:
    StatPearls (NCBI)
  • Home Epley instructions (Johns Hopkins):
    Johns Hopkins Health Library
  • Cleveland Clinic Epley overview:
    Cleveland Clinic

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  Primary care physicians and generalists play a vital role in diagnosing, treating, and educating patients with dizziness.
  Knowing when to refer and when to treat confidently in clinic is key to high-value care.

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🧠 Practical Tips for History & Physical Exam

• Don’t ask “Do you feel dizzy?” — Instead, ask “Can you describe what the dizziness feels like?”
• Focus on duration and triggers, not just type: BPPV = short + positional; Stroke = persistent + spontaneous
• HINTS exam is only for AVS: Use it when symptoms are continuous (not for brief, positional vertigo)
• Always test gait or balance: Romberg, tandem gait, and “walk-and-turn” can reveal subtle cerebellar issues
• If in doubt — make them dizzy: Use Dix–Hallpike or stand-up maneuvers to provoke symptoms safely
• Use Frenzel goggles or video tools: These enhance subtle peripheral nystagmus that patients may suppress

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🏵️ Clinical Pearl

“Most patients with vertigo don’t need imaging. They need a careful history, a good Dix–Hallpike, and your confidence.”
— Dr. Peter Johns, Otolaryngologist

In short: trust your exam, not just your scanner. A confident, structured approach is the best diagnostic tool.

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🗣️ OET Speaking Session – Dizziness (BPPV)

👥 Scenario

You are a doctor in a general practice clinic. A 72-year-old woman presents with sudden spinning dizziness triggered by head movement, especially when getting out of bed. The episodes are brief and improve when lying still. You suspect benign paroxysmal positional vertigo (BPPV).

🎯 Your Task

• Explain what BPPV is in simple terms
• Describe the safety and purpose of the Dix–Hallpike and Epley maneuvers
• Address concerns about recurrence and safety at home
• Provide reassurance and instructions for follow-up care

🗣️ Suggested Doctor Statements

• Explaining the condition:
  “This type of dizziness is usually caused by small crystals in your inner ear that shift when you move your head.”
• Clarifying that it’s not dangerous:
  “Although it feels scary, this condition is benign and not life-threatening.”
• Reassuring the patient:
  “It’s a common cause of dizziness, and we can often improve it right here in the clinic.”
• Introducing the diagnostic maneuver:
  “I’d like to perform a simple test that may briefly trigger your symptoms, but it will help us confirm what’s going on.”
• Explaining the Epley maneuver:
  “We’ll guide your head through a series of movements to reposition the crystals in your ear — it usually brings relief quickly.”
• Encouraging follow-up:
  “If it happens again, you can use home exercises I’ll teach you — and we can reassess if needed.”

💬 Common Patient Cues & Sample Doctor Responses

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✉️ OET Writing Task – Sample Referral Letter

Today’s Date

Dr. Laura Chen
Otolaryngology Department
Central General Hospital

Re: Mrs. Janet Edwards, 72 years old

Dear Dr. Chen,

I am referring Mrs. Janet Edwards, a 72-year-old woman, for further evaluation of suspected benign paroxysmal positional vertigo (BPPV).

She presented to our clinic this morning with a two-day history of brief, spinning dizziness triggered by positional changes such as getting out of bed or turning her head. Each episode lasts under one minute and resolves with rest. There is no associated hearing loss, tinnitus, headache, or neurological deficit.

Her past medical history includes well-controlled hypertension. She is taking amlodipine and has no history of vestibular disorders or cerebrovascular events.

The Dix–Hallpike maneuver elicited right-sided torsional nystagmus consistent with posterior canal BPPV. We performed an Epley maneuver, which resulted in partial symptom relief. There are no red flag signs to suggest a central cause at this time.

I would appreciate your assessment to confirm the diagnosis and consider vestibular rehabilitation if symptoms persist.

Kind regards,

Dr. [Your Name]
General Practitioner

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🧭 Take-Home Message – Summary & Reflection

Dizziness is a common but often confusing complaint. By following a structured approach, you can quickly narrow your differential and avoid unnecessary tests or referrals.

🔑 Key Points to Remember

• Start with classification: Is it vertigo, presyncope, disequilibrium, or lightheadedness?
• Focus on duration and triggers: BPPV is short and positional; central causes are persistent and spontaneous
• Use the HINTS exam carefully: Only apply it for continuous symptoms — not brief episodes
• Dix–Hallpike + Epley = Powerful combo: You can diagnose and treat BPPV without imaging
• Reassure and empower: Teach home maneuvers and explain the benign nature of BPPV

🎁 Final Thought

More than 80% of dizziness diagnoses can be made through careful history and physical exam. Trust your clinical reasoning, and remember — the best test may be the one you perform with your own hands.

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🔗 Related Articles

• 🧠 Approach to Syncope – Differentiate from true vertigo
• 😴 Fatigue and Generalized Weakness – Consider anemia and hypotension
• 📈 Palpitations – Orthostatic causes and autonomic dysfunction
• 📉 Involuntary Weight Loss – Dizziness due to malnutrition or dehydration
• 🤢 Nausea and Vomiting – When dizziness presents with GI symptoms
• 🇯🇵【日本語版】めまいの診かた（症候別アプローチ）

📝 Want to practice clinical reasoning with real-life scenarios?
Check out our Mock Patient Script – Dizziness, where you can work through 3 interactive cases: positional vertigo, brainstem stroke, and presyncope. Perfect for OSCE prep and English medical interviews.

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📚 References

1. Japan Society for Equilibrium Research. Clinical Practice Guideline for Vertigo 2022. Kanehara Shuppan.
2. Yamanaka T, ed. Vertigo Handbook for Primary Care. Shindan To Chiryo Sha; 2022.
3. Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol. 2007;20(1):40–46.
4. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341(21):1590–1596.
5. Post RE, Dickerson LM. Dizziness: A diagnostic approach. Am Fam Physician. 2010;82(4):361–368.
6. UpToDate. Evaluation of the patient with vertigo. Last updated 2024.
7. Migliaccio AA, et al. Medically unexplained dizziness in the elderly: Diagnosis and treatment. Clin Geriatr Med. 2010;26(2):231–246.

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