There are very few chief complaints that make providers cringe more than “dizziness.”
It’s vague — four different patients can say they’re “dizzy” and mean four completely different things.
And the differential is frustrating: it could be something serious, or something totally benign.
Early on in your career, dizziness can feel like one of those complaints where you’re either completely overdoing it or constantly worried you’re missing something big.
Here are a few things to keep in mind when you’re working these patients up.
TL;DR — What You Actually Need to Know
- Purpose: Help you stop overthinking dizziness and focus on what actually matters.
- Do this first: Figure out what the patient means when they say “dizzy.”
- Red flags: Neuro deficits, syncope, exertional symptoms, abnormal vitals, new severe headache.
- Initial checks: Vitals (including orthostatics), glucose, focused neuro exam, cardiac exam.
- First-line approach: Categorize first. Diagnose second.
- Follow-up: If you can’t confidently put it in a bucket, refer for further workup.
First Things First: What Does “Dizzy” Mean?
If a patient says they’re dizzy, your first job is figuring out what they actually mean.
Most patients use “dizzy” as a catch-all word, so you have to get specific. I usually ask:
- Does the room feel like it’s spinning?
- Do you feel like you’re about to pass out?
- Do you feel off balance when you walk?
- Or do you just feel lightheaded or weird?
That clarification alone usually clears up a lot.
After that, most “dizziness” fits into one of four buckets:
- Vertigo: spinning or motion sensation
- Presyncope: feels like they might faint
- Disequilibrium: off balance, unsteady
- Nonspecific lightheadedness: vague, hard to describe
Once you know which bucket you’re dealing with, everything gets a little easier.
Red Flags You Can’t Ignore
If you see any of the following, your differential should shift immediately:
- Syncope or near syncope: arrhythmias, ischemia, or significant orthostasis
- New focal neurologic findings: concerning for central causes like stroke or other intracranial pathology
- Chest pain, palpitations, or shortness of breath: consider arrhythmia or ischemia
- Exertional dizziness: red flag for cardiac disease until proven otherwise
- Abnormal vitals that don’t normalize: hypotension, bradycardia, tachycardia, hypoxia, or fever should make you pause and reassess
- New, severe headache: especially if it’s different from their usual headaches (think intracranial bleed, mass, vascular causes)
- Persistent vomiting: can point toward central causes, severe vertigo, or metabolic issues
If you’re seeing any of these, it’s no longer a “let’s see how it goes” visit. These patients need further workup at a higher level of care.
A Reasonable Outpatient Approach
Once you’ve ruled out obvious red flags, here’s a simple approach to working these patients up:
Vitals
Including orthostatic vitals. As a reminder, orthostatic hypotension is defined as:
- Systolic BP drops ≥ 20 mmHg
- Diastolic BP drops ≥ 10 mmHg
- Heart rate increases ≥ 30 bpm (≥ 40 bpm in adolescents)
Glucose
Especially if the patient has diabetes, poor oral intake, recent illness, or vague symptoms.
EKG
Look for rhythm issues or ischemic changes. Common things you’ll actually catch include:
- atrial fibrillation or other tachyarrhythmias
- bradycardia or heart block
- ischemic changes
- prolonged QT
Focused exam
You don’t need a head-to-toe exam, but you do need to be hit the big ones:
- A neuro exam (practice this until you feel fully comfortable with it, here’s a good one — start at 0:54)
- A cardiac exam
- Gait if balance is part of the complaint
Medication review
Ask about new meds, recent dose changes, antihypertensives, diuretics, and anything sedating.
Context matters
Has the patient had a recent illness, dehydration, poor sleep, stress, or anxiety?
From there, the plan is usually pretty straightforward:
- Rehydrate if needed
- Adjust or hold contributing meds when appropriate
- Treat BPPV if that’s the pattern
- Reassure with very clear return precautions
A Quick Pattern Cheat Sheet
| What They’re Feeling | What to Watch For | What It Usually Means |
| Spinning | Neuro deficits, gait issues | Central causes |
| Spinning | Positional, no neuro findings | BPPV |
| About to faint | Exertional symptoms | Cardiac |
| Vague/lightheaded | Illness, dehydration | Benign |
A Few Common Questions
How do I check orthostatic vitals correctly?
Have the patient lie flat for about 5 minutes, then check BP and heart rate. Stand them up, then repeat at 1 and 3 minutes after standing. A drop in blood pressure or a significant rise in heart rate, especially if it reproduces symptoms, is meaningful. Even if the numbers don’t hit textbook cutoffs, symptoms count.
When is imaging actually indicated for dizziness?
Imaging is appropriate when there are focal neurologic deficits, concern for central causes, or when the exam and history don’t line up. It’s not routine for uncomplicated dizziness with a reassuring exam.
What are the common treatments for BPPV?
Dix-Hallpike helps confirm it, and canalith repositioning maneuvers like the Epley are first-line. Vestibular suppressants (e.g., meclizine) may help short-term nausea but don’t fix the problem. Most cases improve with time, reassurance, and proper maneuvers.
Final Thoughts
Dizziness is frustrating mostly because it’s a vague complaint with a wide differential. Don’t overcomplicate it. Clarify the symptom, rule out the dangerous stuff, and take it one step at a time.
If this was helpful, you’d probably like Blox. It’s built around exactly this kind of real-world clinical thinking.