11/13/24, 8\:09 PM Guide | Dizziness history
Dizziness history
Table of contents
Introduction
Dizziness is a common presenting complaint in both general practice and the emergency department. It can be challenging to
obtain a history with this presentation because the term ‘dizziness’ and other commonly used expressions (e.g.
‘funny turn’)
can mean di
This makes it easy for the patient and clinician to misunderstand each other, leading to the risk of diagnostic error. It is
essential to ask the patient to be as speci
Whilst many patients who experience dizziness will have a non-serious cause, it is important not to miss a serious cause
requiring urgent recognition and treatment.
Although this article only covers history taking, a full patient assessment will always include a focused physical examination to
aid the distinction between di
For this OSCE guide, dizziness has been divided into vertigo and non-vertiginous dizziness. This is because there are some
questions which are very speci
of dizziness.
Background
Vertigo
Vertigo is de
motion during otherwise normal head movement.
Vertigo is a symptom which arises as a result of dysfunction in the vestibular system. The causes of vertigo can be divided into
those originating in the inner ear or the vestibular nerve (‘peripheral vertigo’) and those originating in the brain or brain stem
(‘central vertigo’).
1
Although most patients with vertigo will have a peripheral cause, it is essential not to miss the diagnosis of a central
pathology.
Central vertigo
Vascular causes of central vertigo include\:
Posterior circulation stroke\: causes hyper-acute (within seconds) onset of continuous vertigo, which may be so severe that
the patient cannot stand unaided. Although vertigo is the most common symptom (and may be the only symptom),
additional neurological symptoms, including occipital headache, increase the possibility of this diagnosis.
2
Vertebrobasilar insu
atherosclerosis. Typical presenting symptoms include episodic vertigo, lasting between 30 seconds and 15 minutes,
diplopia, dysarthria, ataxia, drop attacks and clumsiness. Episodes are typically brought on by abruptly standing or turning
the head.
Vertebral artery dissection\: a cause of posterior circulation stroke in young adults, may be traumatic or spontaneous.
Symptoms include headache, dizziness, and neck pain. Predisposing conditions include hypertension, Ehlers-Danlos
syndrome, Marfan syndrome, osteogenesis imperfecta and
3
Other causes of central vertigo include\:
Multiple sclerosis (MS)\: can cause vertigo due to the development of demyelinating plaques in the vestibular pathways.
Vertigo may be associated with diplopia and/or gait problems. MS can also cause peripheral vertigo.
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Posterior fossa tumour\: in addition to vertigo, this condition may present with unilateral hearing loss or tinnitus.
Vestibular migraine\: presents with vertigo along with typical symptoms of migraine, such as unilateral headache,
photophobia and phonophobia. It is largely a diagnosis of exclusion, as it can mimic other causes of central vertigo.
5
Peripheral vertigo
The most common causes of peripheral vertigo include\:
Benign paroxysmal peripheral vertigo (BPPV)\: has a hyper-acute onset and is triggered by movement, typically turning
over in bed. Patients describe short bursts (a few seconds to a minute) of intense vertigo. Repeated episodes are brought on
by head movement. It is often associated with nausea, but not usually with vomiting, and there are no other accompanying
symptoms. Patients may experience a residual sensation of much less severe disequilibrium for several hours afterwards,
but this should not be confused with the persistence of the initial severe vertigo.
Ménière’s disease\: classically consists of a combination of acute vertigo (spontaneous onset and lasts for minutes to hours)
with unilateral aural fullness, tinnitus, and sensorineural hearing loss. Patients will experience repeated episodes of these
symptoms with progressive hearing loss on the a
Vestibular neuronitis/labyrinthitis\: patients experience vertigo which comes on more gradually (usually over several hours),
lasts for several days, and is made worse by movement. 6
It may have a viral aetiology, and there may be preceding
symptoms of an upper respiratory tract infection. Patients usually experience nausea and vomiting, and, in the case of
labyrinthitis, there may be sensorineural hearing loss on the a
Other causes of peripheral vertigo include\:
Other otological conditions\: otitis media with tympanic membrane perforation, cholesteatoma, Ramsay Hunt syndrome.
Medication side e
Persistent postural-perceptual dizziness (PPPD)\: a functional neurological disorder that is thought to re
vestibular system dysfunction. Patients may describe non-spinning vertigo or unsteadiness.
7
Alcohol or substance misuse
Non-vertiginous dizziness
Patients who do not describe a sensation of movement associated with their dizziness are likely to have an alternative cause
of their symptoms.
They may instead be experiencing a sensation of light-headedness, pre-syncope (a feeling of impending loss of
consciousness), or disequilibrium (imbalance).
The two principal groups of causes of these types of dizziness are cardiovascular causes and neurological causes.
8
Cardiovascular causes of dizziness
The reason for the dizziness is usually cerebral hypoperfusion. Cardiovascular causes of dizziness include\:
Myocardial infarction
Cardiac arrhythmia
Acute left ventricular dysfunction
Pulmonary embolism
Orthostatic (postural) hypotension\: the patient feels light-headed or pre-syncopal on moving from a lying or seated
position to standing. This can be caused by either a failure of the normal peripheral vasoconstriction, which occurs on
standing (seen, for example, in Parkinson’s disease), or by volume depletion (e.g. dehydration, sepsis, acute blood loss,
metabolic abnormalities such as hyperglycaemia or hypernatraemia).
Vasovagal pre-syncope (near-fainting)\: bradycardia and/or vasodilatation are triggered by parasympathetic activation, often
in response to a trigger such as heat or prolonged standing. Syncope (fainting) can be averted by the patient recognising the
symptoms and lying down, which increases venous return.
Postural orthostatic tachycardia syndrome (POTS)\: typically a
dizziness and patients have inappropriate tachycardia on standing.
Neurological causes of dizziness
Neurological causes of dizziness include\:
Normal pressure hydrocephalus\: in this condition, the cerebral ventricles are enlarged, but intracranial pressure is normal. It
is associated with ataxia, urinary incontinence, and impaired cognition.
Mal de debarquement syndrome\: a persistent sensation of motion after, for example, a long boat or aeroplane journey.
Other causes of dizziness
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Other causes of non-vertiginous dizziness include\:
Hypoglycaemia
Alcohol
Drug-related\: diuretics may cause volume depletion, whilst anti-hypertensives may cause orthostatic hypotension.
Carbon monoxide poisoning
Psychological\: anxiety can cause dizziness, particularly if it is associated with hyper-ventilation. However, it is important to be
aware that the experience of vertigo and other types of dizziness can be extremely anxiety-provoking. The patient’s
symptoms should not be attributed to anxiety without considering all other potential causes.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Presenting complaint
Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Open vs closed questions
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History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di
History of presenting complaint
Gather further details about the patient’s dizziness using the SOCRATES acronym.
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most
commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not
be relevant to all symptoms.
Site
N/A
Onset
Clarify how and when the dizziness developed\:
" W h e n d i d t h e d i z z i n e s s
" D i d t h e d i z z i n e s s s t a r t s u d d e n l y ( o v e r a f e w s e c o n d s ) ?"
The key here is to identify patients who have experienced a hyper-acute (over a few seconds) onset of their symptoms, which
can be a marker of an acute vascular event (e.g. posterior stroke).
Character
Ask about the speci
" C a n y o u d e s c r i b e t o m e e x a c t l y w h a t t h e d i z z i n e s s i s l i k e ?"
The key here is to distinguish vertigo from other types of dizziness.
True vertigo is a sensation of motion, usually rotation when the patient is still, and/or a sensation of abnormal motion
accompanying normal head movement. Therefore, it is helpful to clarify this by asking\:
" D i d y o u f e e l a s t h o u g h y o u w e r e m o v i n g, o r t h e w o r l d w a s m o v i n g a r o u n d y o u , e v e n w h e n y o u w e r e s t i l l ?"
If the patient struggles to answer this, it may be helpful to give them an example, such as\:
" D i d y o u f e e l l i k e y o u h a d j u s t s t e p p e d o
If the patient has experienced true vertigo, they will probably recognise one or both of these descriptions.
Radiation
N/A
Associated symptoms
Ask if there are other symptoms which are associated with the dizziness\:
“ A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e d i z z i n e s s ?”
Time course
Clarify the time course of the dizziness, and whether it occurs in discrete episodes or is continuous\:
" D o e s t h e d i z z i n e s s c o m e a n d g o , o r i s i t a l w a y s t h e r e ?"
" H o w l o n g d o e s e a c h e p i s o d e o f d i z z i n e s s l a s t ?"
Exacerbating or relieving factors
Ask if anything triggered the dizziness, and if anything makes it better or worse\:
" W h a t w e r e y o u d o i n g w h e n t h e d i z z i n e s s s t a r t e d ?"
“ D o e s a n y t h i n g m a k e t h e d i z z i n e s s w o r s e ?”
“ D o e s a n y t h i n g m a k e t h e d i z z i n e s s b e t t e r ?”
It is particularly helpful to elicit whether there is a positional element to the dizziness.
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Severity
Assess the severity of the dizziness by asking the patient to grade it on a scale of 0-10\:
“ O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e d i z z i n e s s , i f 0 i s n o d i z z i n e s s a n d 1 0 i s t h e w o r s t d i z z i n e s s y o u’ v e e v e r e x p e r i e n c e d ?”
After completing this initial information gathering, you should have established whether the patient is describing vertigo or
non-vertiginous dizziness, the key characteristics of the problem, including onset, associated symptoms, timing, exacerbating
and relieving factors and the severity.
Patients with vertigo
The SAFER mnemonic can help you re
potential diagnoses in a patient with vertigo\:
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Serious causes of the presentation\: if there are features in the history suggestive of any of the causes of central, vascular
vertigo, then the patient is likely to require further investigation on an urgent basis.
Alternative causes of the presentation\: posterior fossa tumours, vestibular migraine. Again, patients with features of these
conditions will require urgent further investigation.
If you have not elicited speci
information which you have gathered and ask yourself whether there are any features which do not
peripheral cause of vertigo. For example, are you considering a diagnosis of vestibular neuronitis, but the patient has
described hyper-acute onset and has vascular risk factors?
Could this be an early or atypical presentation of a condition? For example, could vertigo be an unusual presentation of MS?
Are there red
Red
In a patient with vertigo, the following red
Onset\: hyper-acute onset (over a few seconds) may suggest a central vascular cause.
Associated symptoms\: nausea and vomiting are common to all causes of vertigo and not helpful discriminators.
However, the presence of other neurological symptoms may indicate a central cause. Particularly concerning are\:
headache, neck pain, acute hearing loss, facial or limb weakness, loss of sensation over the face or limbs, dysarthria,
dysphagia, and visual symptoms such as diplopia.
Timing\: Persistent vertigo is more concerning for a central cause than vertigo which has occurred in discrete episodes
(although repeated episodes of vertebrobasilar ischaemia could present as a series of discrete episodes).
Exacerbating and relieving factors\: In general, spontaneous onset vertigo is more concerning for a central cause than
vertigo brought on by being in a particular position or by movement. However, there are exceptions to this, namely
vertebrobasilar insu
be brought on by neck movement or trauma.
Severity\: vertigo so severe that the patient cannot stand unaided is concerning for a central cause.
Presence of vascular risk factors\: this makes a central vascular cause, such as posterior circulation stroke, more
likely. 10
Risk factors include\: age >60; hypertension; hypercholesterolaemia; diabetes; current or ex-smoker and history
of cardiovascular disease.
Patients with non-vertiginous dizziness
The SAFER mnemonic can also help you consider the potential diagnoses in a patient with non-vertiginous dizziness\:
Serious causes of the presentation\: if there are features in the history suggestive of any of the cardiovascular or
neurological causes of dizziness described above, this will require further investigation.
Alternative causes of the presentation\: hypoglycaemia, medication side e
patients with features of these conditions will require urgent further investigation.
If you have not elicited speci
information which you have gathered and ask yourself whether there are any features which do not
serious cause of dizziness. It is especially important not to attribute dizziness to a psychological cause without full
consideration of all of the other possibilities.
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Could this be an early or atypical presentation of a condition? For example, could the dizziness be a presentation of silent
myocardial infarction in a diabetic patient?
Are there red
Red
In a patient with dizziness (but not true vertigo), the following red
Onset\: hyper-acute onset (over a few seconds) may suggest an acute cardiovascular cause.
Associated symptoms\: given the wide range of possible causes, many potential additional symptoms exist. Key
symptoms to exclude include\: chest pain, palpitations, shortness of breath, fever, visual disturbance, ataxia, cognitive
problems.
Exacerbating and relieving factors\: dizziness which is made worse by moving from lying or sitting to standing is
suggestive of either volume depletion or autonomic failure. Symptoms brought on by exertion and relieved by rest
may suggest an acute cardiovascular cause.
Presence of vascular risk factors\: this makes a cardiovascular cause more likely. Risk factors include\: age >60;
hypertension; hypercholesterolaemia; diabetes; current or ex-smoker and history of cardiovascular disease.
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?
Summarising
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.
Signposting
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Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l
Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fever
Cardiovascular\: chest pain, palpitations
Respiratory\: shortness of breath
Gastrointestinal\: vomiting or diarrhoea (possible causes of dehydration leading to cerebral hypoperfusion), gastrointestinal
blood loss (haematemesis, melaena or fresh rectal bleeding)
Genitourinary\: polyuria or polydipsia (suggestive of hyperglycaemia or hypercalcaemia). Menorrhagia is a possible cause of
anaemia in female patients.
Neurological\: sensory or visual disturbances
Musculoskeletal\: limb weakness and joint pain can cause feelings of unsteadiness, as can loss of joint proprioception.
Past medical history
Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
If the patient does have a medical condition, you should gather more details to assess how well-controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
It is important to know whether the patient has experienced similar episodes of dizziness before and, if so, whether they have
sought medical attention for them. This may be reassuring if they have previously been investigated and received a diagnosis
such as vestibular migraine.
However, in this situation, it is essential to maintain an open mind about the current presentation. Firstly, they may be presenting
now with a new condition. For example, a patient with a history of migraine may now have su
diagnosis may have been incorrect, and you may be able to correct it with the new information in front of you.
Examples of relevant medical conditions
A past medical history of particular relevance to dizziness includes\:
Risk factors for vascular disease\: age>60, hypertension, hypercholesterolaemia, diabetes, current or ex-smoker
Previous cardiovascular disease\: myocardial infarction or stroke
Malignancy\: especially malignancies that metastasise to the brain (e.g. lung cancer, breast cancer and malignant
melanoma)
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Risk factors for thromboembolic disease\: increase the likelihood of a pulmonary embolus (e.g. history of
thromboembolic disease, current malignancy, surgery within the last two months, immobility, lower limb trauma or
fracture and being pregnant or up to six weeks postpartum).
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Conditions which may cause acute blood loss\: menorrhagia, in
Conditions which may cause autonomic failure\: Parkinson’s disease or diabetes mellitus
Conditions which may cause metabolic abnormalities\: diabetes mellitus and renal disease
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Drug history
Drug history
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over-the-counter medications,
document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
Medication examples
Medications commonly prescribed to patients with dizziness include\:
Prochlorperazine (also known as Stemetil or Buccastem)\: for vertigo
Cinnarizine\: for vertigo
Betahistine\: for Ménière’s disease
Fludrocortisone\: for orthostatic hypotension
Family history
Ask if there is any family history of cardiovascular disease or neurological disease\:
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a h i s t o r y o f h e a r t d i s e a s e , s t r o k e o r o t h e r p r o b l e m s w i t h t h e n e r v e s ?”
Social history
General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stair lift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Understanding the patient’s daily activities and social context allows you to consider the risk posed by further dizziness
episodes.
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Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information
Excess alcohol use can be a cause of dizziness.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Recreational drugs can cause dizziness.
Fluid intake
Patients with poor
Occupation
Ask about the patient’s current occupation\:
Identify any high-risk activities (e.g. working at heights, operating heavy machinery).
If the patient is experiencing episodes of dizziness and works with heavy machinery or at heights, it is important to advise
them to take time o
Driving
If the patient drives and has presented with dizziness, it is important to advise them not to drive until they have been fully
investigated and to inform the relevant driving authority (e.g. Driver and Vehicle Licensing Agency) of their current medical
issues.
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Reviewer
Dr Paul Molyneux
Consultant Neurologist
West Su
References
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Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/history/dizziness-history/ 10/10