Admission Checklist

• ABC's: Assess for signs of hemodynamic instability or neurologic compromise.
  
  • Airway: Ensure patient can protect their airway, especially if altered or vomiting.
  • Breathing: Assess for hypoxia, which may suggest PE or ACS.
  • Circulation: Check for hypotension (hemorrhage, sepsis, orthostasis), bradycardia, or tachycardia (arrhythmia). Establish IV access.
• Triage: Use timing and triggers to categorize the dizziness.
  • Acute Vestibular Syndrome (AVS): Continuous vertigo for >24 hours. Use the HINTS exam to differentiate central vs. peripheral cause.
  • Episodic Vestibular Syndrome (EVS): Recurrent, transient episodes. Differentiate triggered (e.g., BPPV, orthostasis) vs. spontaneous (e.g., Vestibular Migraine, Meniere's, TIA).
  • Stroke Risk: ABCD2 score can be used to assess TIA risk, but the HINTS exam is superior to help screen for stroke as athe etiology of AVS.
• Chart Check:
  • CVD Risk Factors: HTN, HLD, DM, smoking, AFib, prior stroke/TIA.
  • Meds: Antihypertensives, diuretics, antiarrhythmics, antidepressants, sedatives, anticonvulsants, aminoglycosides. Check for recent changes.
  • History: Migraines, Meniere's, BPPV, recent head/neck trauma, recent viral illness.
• Can’t Miss:
  • Posterior circulation stroke (cerebellar or brainstem)
  • Vertebral artery dissection
  • Acute Coronary Syndrome (ACS)
  • Pulmonary Embolism (PE)
  • Significant arrhythmia
  • Intracranial hemorrhage
  • Sepsis / Severe dehydration
  • Carbon monoxide poisoning
• Admission Orders:
  • EKG: On all patients.
  • Imaging:
    • MRI/MRA Brain & Neck: Test of choice for suspected central etiology (e.g., positive HINTS, focal neuro deficits). Much more sensitive than CT for posterior fossa pathology.
    • CTA Head & Neck: If concern for vascular dissection.
    • CT Head (non-contrast): Limited utility for acute ischemic stroke but can rule out hemorrhage.
• Initial Treatment to Consider:
  • Stroke: Activate stroke protocol if indicated.
  • BPPV: Perform Epley maneuver if posterior canal BPPV confirmed by Dix-Hallpike.
  • Orthostasis: IV fluids, review and hold offending medications.
  • Symptomatic Relief: For peripheral vertigo (e.g., vestibular neuritis), consider short-term vestibular suppressants.
    • Antihistamines: Meclizine 25-50 mg PO q6-8h PRN. Cautious use in elderly patients.
    • Benzodiazepines: Lorazepam 0.5-1 mg PO/IV PRN for severe vertigo/vomiting (use sparingly and for <72h).
    • Antiemetics: Ondansetron 4-8 mg PO/IV q8h PRN.
  • Safety: Strict fall precautions for all patients.

HPI Intake

• Timing: Onset (sudden vs. gradual)? Duration of episodes (seconds, minutes, hours, days)? Constant or intermittent? Frequency?
• Triggers: Triggered by change in head/body position (e.g., rolling in bed, looking up)? Triggered by rising from sitting/lying (orthostasis)? Spontaneous onset at rest? Triggered by cough/sneeze/strain (Valsalva)?
• Symptom Character: Sensation of motion/spinning (vertigo)? Feeling of impending faint/blackout (presyncope)? Imbalance or unsteadiness, primarily with walking (disequilibrium)? Vague "lightheadedness" or "wooziness"?
• Associated Central Sx (Red Flags): The "5 D's" - Diplopia (double vision), Dysarthria (slurred speech), Dysphagia (trouble swallowing), Dysmetria (limb clumsiness), or sudden Deafness? New severe headache or neck pain? Focal weakness or numbness?
• Associated Peripheral Sx: Hearing loss (unilateral?), tinnitus, aural fullness/pressure (suggests Meniere's or labyrinthitis)?
• General Associated Sx: Nausea/vomiting? Chest pain, palpitations, dyspnea? Fever, signs of infection? Recent head or neck trauma?
• PMH: History of migraines, AFib, CAD, prior stroke/TIA, valvular disease, DM, HTN?
• Meds/Substances: New medications or dose changes? Use of antihypertensives, diuretics, sedatives, alcohol?

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High-Yield Question Flow

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1. Symptom Timing & Pattern (Establish the Vestibular Syndrome)

This first step is the most critical for categorizing dizziness.

1.1. "When exactly did this dizziness first begin?"

1.2. "Did it start suddenly over seconds, or did it come on more gradually over hours or days?"

1.3. "Since it started, has the dizziness been constant and continuous, or does it come and go in spells?"

→ If continuous (Acute Vestibular Syndrome):1.3.1. "How long has it been present without stopping (hours, days)?"1.3.2. "Does moving your head make the constant dizziness worse, or does it trigger a brand new spell of dizziness?" (Exacerbation vs. Trigger is a key distinction).

→ If it comes and goes (Episodic Vestibular Syndrome):1.3.3. "How long does a typical spell last? (seconds, minutes, or hours?)"1.3.4. "How frequently do these spells happen? (daily, weekly, monthly?)"

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2. Triggers (Differentiate Episodic Syndromes & Identify Provoking Factors)

Ask this if the patient reports episodic spells from Q1.

2.1. "What seems to bring on a spell of dizziness?"

2.2. "Is it triggered by a change in position, like rolling over in bed, lying down, or looking up?" (Suggests BPPV)

2.3. "Does it happen specifically when you stand up from a sitting or lying position?" (Suggests orthostatic hypotension)

2.4. "Or do the spells happen spontaneously, without any specific movement or trigger?" (Suggests Vestibular Migraine, Meniere’s, TIA)

2.5. "Have you noticed triggers like coughing, sneezing, straining, or loud noises?" (Suggests perilymphatic fistula or SCD)

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3. Symptom Quality & Character

While less reliable for diagnosis, this helps build the clinical picture.

3.1. "Which of these best describes the feeling: a sensation of spinning (vertigo), feeling lightheaded like you might faint (presyncope), or feeling unsteady and off-balance on your feet (disequilibrium)?"

3.2. If spinning: "Does it feel like you are moving, or like the room is moving around you?"

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4. Associated Neurologic Symptoms (Screen for Central Causes/Stroke)

The "5 D's" and other red flags.

4.1. "During these spells, have you had any of the following?"

• "New, sudden, or severe headache, especially in the back of your head?"
• "Diplopia (double or blurry vision)?"
• "Dysarthria (slurred speech or trouble speaking)?"
• "Dysphagia (difficulty swallowing)?"
• "Dysmetria (clumsiness, or trouble with coordination in your arms or legs)?"
• "Weakness or numbness in your face, arm, or leg, especially on one side?"

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5. Associated Otologic & Systemic Symptoms (Clues for Peripheral & Other Causes)

5.1. "Any changes in your hearing? → If yes: "Is it in one ear or both? Is the hearing loss constant or does it fluctuate with the dizzy spells?" (Meniere's, Labyrinthitis)

5.2. "Any tinnitus (ringing in your ears) or a sense of fullness or pressure in one ear?" (Meniere's)

5.3. "Have you had significant nausea or vomiting?"

5.4. "Any chest pain, shortness of breath, or palpitations (a racing or fluttering heart)?" (Cardiovascular cause)

5.5. "Have you had a recent fever, cold, or other viral illness?" (Vestibular Neuritis/Labyrinthitis)

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6. Severity and Functional Impact

6.1. "On a scale of 0-10, with 10 being the worst imaginable, how severe is the dizziness during an episode?"

6.2. "When the dizziness is at its worst, are you able to walk without help?"

→ If unable to walk: "Can you sit up straight without support?" (Inability to sit/stand unaided is a major red flag for a central cause).

6.3. "Have you fallen because of the dizziness?"

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7. Relevant Patient History & Risk Factors

7.1. "Have you ever had anything like this before?"

7.2. Vascular Risk: "Do you have a history of high blood pressure, high cholesterol, diabetes, atrial fibrillation, heart disease, or a previous stroke/TIA?"

7.3. Migraine History: "Do you, or does anyone in your close family, have a history of migraine headaches?"

7.4. Trauma: "Any recent head or neck injury, even a minor whiplash injury?"

7.5. Psychiatric History: "Do you have a history of anxiety, panic attacks, or depression?"

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8. Medications & Substances

8.1. "Can we review all of your current medications, including any over-the-counter drugs or supplements?" (Focus on antihypertensives, diuretics, aminoglycosides, sedatives, antidepressants).

8.2. "Have you started any new medications or had any dose changes recently?"

8.3. "Any recent alcohol, cannabis, or other recreational drug use?"

8.4. "How much caffeine do you typically consume?"

To Note on Exam

• Vitals: Orthostatic BP and HR (measure after lying supine for 5 min, then at 1 and 3 min after standing). Check for fever, hypoxia.
• General: Pallor, diaphoresis (suggests presyncope). Signs of dehydration.
• Neuro: A full, targeted exam is critical.
  • Oculomotor Exam / HINTS (for patients with Acute Vestibular Syndrome):
    • Head Impulse (HI) Test: Patient fixates on your nose. Rapidly turn their head ~15 degrees. Corrective saccade back to target is abnormal (reassuring; suggests peripheral lesion). Inability to perform or a normal test (eyes stay fixed) is worrisome for a central cause.
    • Nystagmus (N): Assess in primary, right, and left gaze. Note direction (horizontal, vertical, torsional). Peripheral: Unidirectional, horizontal, suppressed by visual fixation. Central: Bidirectional (gaze-evoked), purely vertical or torsional, not suppressed by fixation.
    • Test of Skew (TS): Alternate cover test. Vertical re-alignment of an eye upon uncovering is abnormal (worrisome for a brainstem lesion).
  • Cranial Nerves: Assess for facial droop, dysarthria, dysphagia, diplopia, visual field cuts.
  • Cerebellar: Finger-to-nose and heel-to-shin for dysmetria.
  • Gait: Assess ability to sit unsupported, stand, and walk. Inability to stand or walk unassisted is a major red flag for a central cause.
• Provocative Maneuvers (for patients with Triggered Episodic Vertigo):
  • Dix-Hallpike Maneuver: To diagnose posterior canal BPPV. A positive test elicits transient (typically <60s) upbeat torsional nystagmus.
• Cardiac: Murmurs, rubs, gallops, irregular rhythm.

Etiology/Differential

• Peripheral Vestibular: Benign paroxysmal positional vertigo (BPPV), vestibular neuritis, labyrinthitis, Meniere's disease, vestibular migraine.
• Central Vestibular: Posterior circulation stroke (cerebellar, brainstem), TIA, vertebral/basilar artery dissection, multiple sclerosis, posterior fossa mass/tumor.
• Cardiovascular: Orthostatic hypotension, arrhythmia (AFib, SVT, bradycardia), acute coronary syndrome, severe aortic stenosis, pulmonary embolism, vasovagal/neurally-mediated syncope.
• Systemic/Other: Dehydration/hypovolemia, hemorrhage (e.g., GI bleed), sepsis, anemia, hypoglycemia, medication side effect, panic/anxiety disorder, persistent postural-perceptual dizziness (PPPD), CO poisoning.

If You Remember Nothing Else

The primary goal when evaluating a dizzy patient is to differentiate dangerous central causes from more benign peripheral or systemic etiologies. Do not rely on the patient’s description of their dizziness (e.g., "spinning" vs. "lightheaded"). Instead, focus on the Timing and Triggers to build your differential. Divide the presentation into clinical syndromes: Acute Vestibular Syndrome (AVS - continuous dizziness >24h) or Episodic Vestibular Syndrome (EVS - transient attacks).

For patients with AVS, a stroke is the main concern. The HINTS exam (Head-Impulse, Nystagmus, Test of Skew) is your most powerful tool and is more sensitive than an early MRI for posterior circulation stroke. Any one "dangerous" finding (a normal Head-Impulse, direction-changing Nystagmus, or a positive Test of Skew) should prompt an urgent MRI/MRA and neurology consultation. Inability to stand or walk unassisted is a major red flag for a central cause.

For patients with EVS, determine if episodes are triggered or spontaneous. If triggered by position changes and lasting seconds, suspect BPPV and confirm with a Dix-Hallpike maneuver. If triggered by standing, check orthostatics. If episodes are spontaneous, consider vestibular migraine or TIA, especially in patients with vascular risk factors. Always perform a thorough neurologic exam on every dizzy patient to screen for the "5 D's" (Diplopia, Dysarthria, Dysphagia, Dysmetria, Deafness) that point toward a brainstem or cerebellar lesion.