Dizziness/Vertigo Evaluation Note

Date/Time: [Encounter date and time]

Setting: [ED / clinic / urgent care]

Clinician: [Name, credentials]

History Source & Reliability: [Historian(s) and factors affecting reliability]

Interpreter: [Modality and language] (Include only if language services were used)

Chief Complaint

[Presenting concern, using patient wording in quotes when illustrative] (Prefer descriptive terms such as dizziness, vertigo, lightheadedness, or imbalance; avoid diagnostic labels.)

History of Present Illness

(Compose 2–4 concise paragraphs.)

[Patient's description of the sensation and context] [Clinician's classification: vertigo / presyncope or lightheadedness / imbalance or disequilibrium / nonspecific dizziness] (These may overlap; clearly document if multiple categories apply.)

Timing and Triggers: [Onset date/time] [Sudden / gradual] [Continuous / episodic]; [If episodic: typical episode duration and frequency]. [Triggers: head position change, rolling in bed, standing, exertion, visual motion, Valsalva, other]. [Relieving factors and responses].

Dizziness Syndrome: [triggered episodic vestibular syndrome (t-EVS) / spontaneous episodic vestibular syndrome (s-EVS) / acute vestibular syndrome (AVS) / chronic or persistent dizziness]

Functional Impact: [Ambulation ability: independent / needs assistance / unable to stand] [Falls or near-falls with injury details and anticoagulation status if relevant] [Oral intake tolerance].

Associated Symptoms: [Neurologic: focal weakness or numbness, facial asymmetry, speech changes, diplopia, vision changes, severe headache, neck pain, recent head/neck trauma] [Otologic: hearing changes, tinnitus, ear fullness, recent URI] [Presyncope/Systemic: chest pain, palpitations, dyspnea, exertional component, syncope, bleeding signs]. (Only include items explicitly reported; prioritize dangerous features.)

Relevant History: [Prior similar episodes and prior diagnoses: BPPV, vestibular neuritis, Ménière disease, vestibular migraine] [Vascular risk factors: prior stroke/TIA, atrial fibrillation, hypertension, diabetes, smoking] [Migraine history] [Baseline mobility] [Pre-arrival treatments and response]. (Omit pre-arrival treatments if none.)

Stroke Timing: [Last known well] [Symptom evolution since onset]. (Include only if stroke is a diagnostic consideration.)

Review of Systems

[Focused ROS pertinent to suspected syndrome] (Align with timing/trigger-based syndrome; note if limited by circumstances such as active vomiting or altered mental status. Omit this section entirely if it adds nothing beyond HPI.)

Past Medical History

[Vascular, cardiac, neurologic, vestibular conditions prioritized; other relevant chronic conditions]

Medications

[Current medications with emphasis on antihypertensives, diuretics, vestibular suppressants, ototoxic agents, QT-prolonging drugs, anticoagulants/antiplatelets]

Allergies

[Drug allergies with reaction type]

Social History

[Alcohol and substance use] [Occupation or activities relevant to risk if applicable] [Pregnancy status if applicable]

Physical Examination

Vital Signs

[Standard vitals]

Orthostatic Vitals: [Protocol: supine rest duration, timing of standing measurements] [BP/HR supine] [BP/HR standing] (Include when presyncope, orthostatic symptoms, volume depletion, or antihypertensive/diuretic contribution is suspected.)

General

[Appearance, hydration status, acute distress]

HEENT

[Ear exam findings] (Include when otologic symptoms or suspected peripheral vestibular pathology; otherwise brief or omit.)

Cardiovascular

[Rhythm, murmurs, volume status as relevant]

Neurologic Examination

Mental Status: [Findings]

Cranial Nerves: [Pupils, extraocular movements, facial symmetry, speech]

Motor/Sensory: [Screening findings]

Coordination: [Finger-to-nose and other testing]

Gait: [Unassisted / assisted / unable to stand] [Tandem gait and Romberg if tested] (If unsafe to test, document reason.)

Vestibular and Oculomotor Examination

(Include elements aligned with the identified Dizziness Syndrome. Do not document tests that were not performed; if testing was deferred, document reason.)

Spontaneous Nystagmus (for AVS): [Present at primary gaze: yes / no] [Direction: right-beating / left-beating / vertical / torsional] [Direction changes with gaze: yes / no] [Fixation suppression: yes / no]

HINTS Examination: (Appropriate only for AVS with active symptoms and trained examiner.)

• Head Impulse Test: [Normal / abnormal] [Laterality if abnormal]
• Nystagmus: [Unidirectional / direction-changing] [Vertical component: present / absent]
• Test of Skew: [Absent / present]
• Interpretation: [Peripheral-appearing / central-appearing / equivocal] [Brief rationale]

(If any HINTS component not completed, document reason and label overall HINTS as incomplete. Note examiner training status if relevant to interpretation.)

Bedside Hearing Screen: [Finger rub: symmetric / decreased unilaterally] [New vs baseline] (Include when audiovestibular ischemia is considered.)

Positional Testing (for t-EVS/suspected BPPV):

• Dix-Hallpike: [Side tested] [Vertigo provoked: yes / no] [Latency] [Nystagmus: torsional upbeating pattern, direction] [Result: positive / negative / equivocal]
• Supine Roll Test: [Horizontal nystagmus pattern: geotropic / apogeotropic] [Side predominance] (Include only if performed.)

(If positional testing not performed, document reason.)

Diagnostic Results

Point-of-Care Tests: [Test, indication, and key result]

ECG: [Rate, rhythm, conduction, QT, ischemia interpretation] [Indication]

Laboratory Studies: [Tests obtained with indication and pertinent results]

Imaging: [Modality and key findings] [Clinical triggers: central-appearing exam, inability to ambulate, focal deficits, severe headache, high-risk features]

Imaging Not Obtained: [Reasoning when bedside evaluation supports peripheral diagnosis without red flags] (Include when applicable to document clinical reasoning.)

Pending Results: [Items pending] [Owner responsible for follow-up]

Assessment

[Synthesis of dizziness pattern, key history and exam findings, and reasoning favoring peripheral vs central vs systemic etiology]

Working Diagnosis: [Primary diagnosis]

Differential Diagnosis:

• Peripheral vestibular: [BPPV / vestibular neuritis / Ménière disease / vestibular migraine / other]
• Central/neurologic: [Posterior circulation stroke or TIA / other structural causes]
• Systemic: [Orthostatic hypotension / volume depletion / arrhythmia / medication effect / anemia / other]

Risk Statement: [Presence or absence of high-risk features and how this informed testing and disposition] (Avoid definitive exclusion statements; document evidence supporting or arguing against serious diagnoses.)

Plan

(Use problem-oriented format. Include only applicable sections below.)

BPPV (positive positional test): [Repositioning maneuver performed, e.g., Epley] [Patient tolerance and immediate response] [Vestibular suppressants: not routinely indicated; if used, document rationale and short duration] [Recurrence counseling, home safety, follow-up plan for persistent/atypical symptoms]

Suspected Vestibular Neuritis or Peripheral AVS: [Symptom management: antiemetics, hydration, short-term vestibular suppressants with stop date if needed] [Early mobility encouragement] [Vestibular rehabilitation referral if appropriate] [Return precautions for evolving neurologic symptoms]

Concern for Central Cause: [Stroke protocol activation if applicable] [Imaging and testing plan with rationale] [Specialist consultation] [Disposition decision] [Last known well and time-sensitive documentation]

Presyncope/Orthostatic Etiology: [Orthostatic vital interpretation] [ECG interpretation] [Medication adjustment plan and responsible clinician] [Hydration guidance] [Workup for anemia or bleeding if indicated] [Disposition criteria]

Medication-Related Dizziness: [Suspected agent] [Plan for dose adjustment or discontinuation] [Alternatives and monitoring]

Falls/Gait Instability/Older Adults: [Fall risk assessment] [Home safety recommendations] [Assistive device needs] [Driving or work restrictions if applicable] [Referrals for fall prevention]

Procedures

(Include only if Dix-Hallpike, canalith repositioning maneuver, or formal HINTS examination was performed as a therapeutic or diagnostic procedure.)

Procedure: [Name of procedure]

Indication: [Reason for procedure]

Technique: [Steps performed and laterality]

Findings: [Objective findings]

Patient Tolerance: [Well tolerated / complications]

Post-Procedure Status: [Immediate outcome]

Disposition

Disposition: [Discharge / observation / admission] — [Patient condition]

Follow-up: [PCP / neurology / ENT / vestibular physical therapy] [Timeframe]

Pending Results: [Owner responsible for follow-up notification and plan]

Return Precautions:

• New or worsening weakness or numbness
• Speech or vision changes
• Inability to walk
• Severe headache or neck pain
• Persistent vomiting or inability to stay hydrated
• Fainting
• Chest pain or palpitations

Medical Decision Making

Problems Addressed: [Problems with acuity/severity level]

Data Reviewed and Ordered: [History sources] [External records reviewed] [Independent historian] [Tests ordered with rationale] [Independent interpretation if performed]

Risk of Management: [Prescription drug management] [Hospitalization decision] [High-risk diagnoses evaluated and how risk influenced decisions]