Priority Topic: Dizziness

Key Feature 1: In patients complaining of dizziness, rule out serious cardiovascular, cerebrovascular, and other neurologic disease (ex: arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 2: In patients complaining of dizziness, take a careful history to distinguish vertigo, presyncope, and syncope.
Skill: Clinical Reasoning
Phase: History

Key Feature 3: In patients complaining of dizziness, measure postural vital signs.
Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills
Phase: Physical

A 52 year old female with a past medical history significant for migraines with visual aura presented to clinic today with a concern of new episodic dizziness that she had been experiencing over the course of one week. The episodes were characterized as lasting around 2 minutes followed by complete resolution, and consisted of her veering to her right side. She stayed down on the ground, afraid to get up, until the sensation passed. Her most recent episode scared her so much she came to tears. All episodes occurred while walking, and were not associated with any proceeding orthostatic positional change. She did not lose consciousness (aka the episodes were not syncopal), nor did she feel lightheaded or as though she was going to faint (presyncopal). She did not sustain any trauma from falling. She did not experience any palpitations, chest discomfort, or dyspnea. She did not feel as though she or the environment around her was "spinning" during the episodes of dizziness. On examination she appeared well and without reproducible dizziness, including a negative Dix-Hallpike maneuver. Her vital signs were all in the normal range and she did not have orthostatic hypotension. Neurological examination was unremarkable. 

The great majority of people presenting with a concern of dizziness have a benign underlying etiology. However, it can also be the same presenting concern from patients who have a serious disease process underlying the symptom. It is important to always clinically assess for serious cardiovascular disease (loss of consciousness, palpitations, chest discomfort, dyspnea), or cerebrovascular or neurologic disease (sudden onset and persistent symptoms in a patient who is at least 60 years old or who has vascular risk factors, an associated headache, or any focal neurological signs). This patient did not have any of these risk factors, and given the lack of persistence and spontaneous onset of every episode, her dizziness would best fit a description of vertigo.