1. 🧼 Opening the Consultation

• Wash or sanitise hands
• Introduce yourself: "Hi, my name is (Name), one of the physician associates"
• Confirm the patient's full name and date of birth
• Gain consent: "Would it be okay if I asked you some questions about the dizziness you've been experiencing?"
• Check that the patient feels safe sitting where they are, particularly if they are currently very dizzy or unsteady

2. ❓ Presenting Complaint

• Start with an open question:
  • "Can you tell me what's been happening?"
  • "What do you mean when you say you feel dizzy?"
• Clarify the sensation rather than assuming "dizziness" means vertigo:
  • "Does it feel as though you or the room is spinning?"
  • "Do you feel as though you might faint or pass out?"
  • "Do you feel unsteady when walking?"
  • "Or is it more of a vague light headed or floating feeling?"
• If the patient says…	You should consider…
  "The room spins"	Vertigo - consider vestibular causes such as BPPV, vestibular neuritis, labyrinthitis, Ménière's disease or vestibular migraine
  "I feel like I'm going to faint"	Presyncope - consider postural hypotension, vasovagal episodes, arrhythmia, dehydration or anaemia
  "I'm unsteady when I walk"	Disequilibrium - consider neurological, vestibular, sensory or medication-related causes
  "It happens when I roll over in bed"	BPPV
  "It happens when I stand up"	Postural hypotension
  "I get dizzy with palpitations"	Possible cardiac arrhythmia
  "It suddenly started and I can't walk properly"	Acute vestibular syndrome - central causes including posterior circulation stroke must be considered

3. 🩺 History of Presenting Complaint

• Onset: "When did the dizziness first start?"
  Sudden onset raises concern for BPPV, acute vestibular disorders, cardiovascular causes and posterior circulation stroke. Gradual or recurrent symptoms may suggest medication effects, migraine or chronic vestibular disease.

• What were you doing?: "What were you doing when it started?"
  Turning in bed suggests BPPV. Standing suggests postural hypotension. Exertional symptoms raise concern for a cardiovascular cause.

• Duration: "How long does each episode last?"
  Duration is often more useful than a severity score when distinguishing causes of dizziness.

• Continuous or episodic: "Are you dizzy all the time, or does it come in attacks?"
  Brief triggered episodes favour BPPV. Persistent acute vertigo lasting hours to days suggests an acute vestibular syndrome and requires careful assessment for central causes.

• Triggers: "Does anything bring the dizziness on?"
  • Turning the head?
  • Rolling over in bed?
  • Looking upwards?
  • Standing from sitting or lying?
  • Exercise?
  True positional triggering from an otherwise settled baseline supports BPPV. Movement simply making continuous vertigo worse does not automatically mean BPPV.

• Progression: "Is it getting better, worse or staying the same?"
• Previous episodes: "Has anything like this happened before?"
  Recurrent stereotyped attacks may suggest BPPV, vestibular migraine, Ménière's disease or an intermittent cardiovascular cause.

• Functional severity:
  • "Are you able to walk normally?"
  • "Have you fallen or needed someone to support you?"
  • "Are you able to carry out your normal activities?"
  New severe gait unsteadiness is particularly important in sudden-onset dizziness and may suggest a central neurological cause.

4. 🧭 Focused Systems Review & Red Flags

• Neurological symptoms:
  • Diplopia or visual disturbance
  • Dysarthria
  • Dysphagia
  • Facial weakness or altered sensation
  • Limb weakness or numbness
  • New severe imbalance or inability to walk normally
  • Loss of coordination
  • New severe headache
  • Altered consciousness
• Ear symptoms:
  • New or sudden hearing loss
  • Tinnitus
  • Ear fullness
  • Ear pain or discharge
  • Recent ear infection
• Migraine symptoms:
  • Headache
  • Photophobia
  • Phonophobia
  • Visual aura
  • Previous migraine history
• Cardiovascular symptoms:
  • Palpitations
  • Chest pain
  • Breathlessness
  • Syncope or near-syncope
  • Symptoms occurring during exertion
• General symptoms:
  • Nausea or vomiting
  • Reduced oral intake
  • Recent diarrhoea or dehydration
  • Recent viral or respiratory illness
  • Recent head or neck trauma
  • Fever or systemic illness

5. 📋 Past Medical History

• Previous episodes of vertigo or dizziness
• Previous BPPV, vestibular neuritis, labyrinthitis or Ménière's disease
• Migraine
• Previous stroke or TIA
• Hypertension
• Diabetes
• Cardiac arrhythmia
• Ischaemic or structural heart disease
• Anaemia
• Neurological conditions
• Ear disease or hearing impairment
• Recent head injury

6. 💊 Drug History & Allergies

• "What medications are you currently taking, including anything bought over the counter?"
• "Have any medications recently been started, stopped or had their dose changed?"
• Consider medications that may contribute to dizziness, including:
  • Antihypertensives
  • Diuretics
  • Alpha-blockers
  • Sedatives
  • Opioids
  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • Other medicines with hypotensive, sedating or ototoxic effects
• Ask about medication adherence
• Allergies: medication + reaction

7. 👨‍👩‍👧‍👦 Family History

• Family history of migraine
• Cardiac arrhythmias
• Inherited cardiac disease or cardiomyopathy
• Stroke at a young age
• Unexplained sudden cardiac death, particularly in younger relatives

8. 🏠 Social History

• Occupation: "What do you do for work?"
  Consider safety critical occupations such as driving, working at height or operating machinery.

• Smoking: current or previous smoking
• Alcohol: amount and frequency
• Recreational drugs
• Hydration: fluid intake and recent dehydration
• Mobility and falls:
  • "Have you fallen because of the dizziness?"
  • "Do you normally use a walking aid?"
• Driving: establish whether symptoms affect safe driving
• Home circumstances: lives alone, stairs, support available
• Impact: work, sleep, exercise and daily activities

9. 💬 ICE - Ideas, Concerns & Expectations

• "Do you have any thoughts about what might be causing the dizziness?"
• "Is there anything in particular you're worried this could be?"
• "What were you hoping we could help you with today?"

10. 🧾 Summarise & Explain Next Steps

"So, you've been experiencing (spinning/light-headedness/unsteadiness) for (duration). It tends to occur when (trigger) and lasts around (duration). You have also noticed (associated symptoms), but you haven't had (important negatives/red flags)".

"I'd like to examine you and perform some targeted checks to help determine whether this is coming from the inner ear, blood pressure, heart or nervous system".

🎓 Present Back to Examiner (PA Format)

"This is a (age)-year-old (man/woman) presenting with a (duration) history of (episodic/continuous) dizziness described as (rotational vertigo/light headedness/unsteadiness). Episodes last approximately (duration) and are triggered by (trigger). Associated features include (relevant positives), with no (key neurological/cardiac red flags). Relevant background includes (PMH/medications). My leading differential is (diagnosis), with differentials including (diagnosis 2) and (diagnosis 3). I would perform observations, lying and standing blood pressure where indicated, a focused cardiovascular, neurological and ear examination and select further investigations according to the suspected cause".

📚 Key References

• NICE. Suspected neurological conditions: recognition and referral (NG127) - dizziness and vertigo in adults.
• NICE. Transient loss of consciousness ("blackouts") in over 16s (CG109).
• NICE. Hypertension in adults: diagnosis and management (NG136) - assessment of postural hypotension.