Family medicine
Dizziness / Vertigo
Dizziness is a nonspecific term encompassing sensations of lightheadedness, unsteadiness, or presyncope, while vertigo is the illusory perception of rotational movement of oneself or the environment, typically arising from vestibular system dysfunction.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | BPPV | Brief (< 60s) vertigo triggered by specific head positions; positive Dix-Hallpike | 「轉頭或者瞓低起身會唔會天旋地轉幾秒鐘？」(Vertigo on positional change, seconds) |
| Acute vestibular neuritis / labyrinthitis | Acute onset, continuous vertigo lasting days, ± URTI prodrome; no hearing loss (neuritis) vs. hearing loss (labyrinthitis) | 「之前有冇傷風感冒？暈係咪成日都暈、暈咗幾日？」(Constant vertigo for days post-viral) | |
| Orthostatic / drug-related dizziness | Presyncope on standing; postural BP drop ≥ 20 mmHg systolic | 「企起身嗰陣會唔會眼前一黑？食緊咩血壓藥？」(Lightheaded on standing) | |
| Serious Not To Miss | Posterior circulation stroke / TIA | Sudden onset; central signs: diplopia, dysarthria, dysphagia, focal weakness, ataxia [1][3] | 「有冇突然間手腳冇力、講嘢唔清楚、嘢睇到兩個？」(Acute neuro deficits) |
| Cerebellar haemorrhage | Sudden severe occipital headache + vertigo + vomiting + truncal ataxia; failed tandem gait [4] | 「有冇突然間後尾枕好痛同嘔？」(Sudden occipital headache) | |
| Cardiac arrhythmia | Palpitations, presyncope/syncope, sudden onset in any position, ± exertional [5] | 「有冇心跳好快或者亂？有冇暈到暈低過？」(Palpitations + LOC) | |
| Pitfalls | Ménière's disease | Episodic vertigo (20 min–hours) + fluctuating SNHL + tinnitus + aural fullness | 「有冇耳鳴、聽嘢差咗、耳仔脹脹哋？每次暈幾耐？」(Triad + duration) |
| Acoustic neuroma (vestibular schwannoma) | Progressive unilateral SNHL > vertigo; CN V/VII involvement late | 「有冇一邊耳仔越嚟越聽唔到？」(Unilateral progressive hearing loss) | |
| Vertebrobasilar insufficiency (VBI) | Episodic vertigo in elderly with vascular RFs; ± other brainstem symptoms | 「你有冇高血壓、糖尿？暈嗰陣有冇手腳痺或者嘢睇唔清？」(Vascular RFs + brainstem Sx) | |
| Masquerades | Drug-induced dizziness | Temporal correlation with medication start/change; antihypertensives, anticonvulsants, aminoglycosides, carbidopa/levodopa [6] | 「最近有冇轉藥或者加新藥？食藥之後有冇特別暈？」 |
| Anaemia | Lightheadedness, pallor, fatigue; not true vertigo | 「有冇面青、容易攰、氣喘？」(Pallor, fatigue) | |
| Hypoglycaemia | Dizziness + hunger + sweating + palpitations; relieved by eating [7] | 「暈嗰陣有冇肚餓、出汗、食咗嘢就好返？」(Hunger + sweating relieved by food) | |
| Depression / Anxiety | Chronic non-specific dizziness; hyperventilation; associated with low mood, worry, panic | 「最近心情點？有冇成日擔心、瞓唔着？」 | |
| Trying to Tell Me Something? | Psychosocial stress / hidden agenda | Fear of stroke (relative had stroke); work stress; carer burden; health anxiety | 「你最擔心啲咩？有冇嘢令你特別唔安樂？」(What worries you most?) |
GC Lecture High-Yield Point
"Dizzy is a non-specific term, especially true in Chinese. Importance of clarification with history taking. Patients may even use the term 'dizzy' for true LOC or headache." — GC 221 [1]
Types of dizziness: Lightheadedness, Pre-syncope, Disequilibrium, Vertigo — GC 221 [1]
"Most important to rule out central cause of vertigo" — GC 221 [1]
"BPPV is common but not all dizziness worsened by motion is BPPV" — GC 221 [1]
"Most common diagnosis of true vertigo is 'vertigo NYD'" — CFB FM02 [8]
"Acute vertigo: viral labyrinthitis, BPV, Eustachian tube dysfunction, Ménière's disease" — CFB FM02 [8]
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, introduce self, build rapport | 「你好，我姓X，係今日嘅醫生。請問點稱呼你？」「今日咩風吹到你嚟睇醫生呀？」 | Warm opening, patient-centred start; shows interpersonal skills |
| 0:30–1:30 | Open-ended HPI: clarify "dizziness" type, onset, duration, triggers, associated Sx | 「你話頭暈，可唔可以形容吓係點暈法？係天旋地轉、定係矇查查想暈低、定係行路唔穩？」「幾時開始？維持幾耐？做咩嘢會差啲？」 | Clarifying the type of dizziness is the single most important first step [1] — directly from GC lecture |
| 1:30–2:30 | Focused Hx: red flags (central cause), hearing, head position, medications, cardiac Sx | 「有冇手腳冇力、口齒不清、嘢睇唔清楚？」「有冇耳鳴、聽嘢差咗？」「轉頭嗰陣會唔會特別暈？」「食緊咩藥？」 | Most important to rule out central cause of vertigo [1]; red flags score heavily |
| 2:30–3:30 | PMHx, DHx, allergy, FHx, social Hx, occupation, functional impact | 「有冇長期病？食緊咩藥？有冇藥物敏感？屋企人有冇類似情況？」「你做邊行㗎？暈嘅時候影唔影響你返工／湊仔／揸車？」 | Comprehensive history; functional impact = social domain for biopsychosocial |
| 3:30–4:30 | ICE: Ideas, Concerns, Expectations | 「你自己覺得點解會暈？」(Ideas)「你最擔心啲咩？」(Concerns)「你今日嚟最希望我哋可以點樣幫到你？」(Expectations) | ICE is a specific exam mark item; uncovers hidden agenda |
| 4:30–5:15 | Signpost, summarise back to patient, check understanding | 「等我總結吓你講嘅嘢，你聽吓啱唔啱……」「有冇嘢我漏咗或者你想補充？」 | Summarising = interpersonal marks; checking = patient-centred care |
| 5:15–6:00 | Explain likely diagnosis, safety-net, close | 「根據你講嘅情況，我覺得最大可能係……我哋會幫你做檢查確認。如果你突然手腳冇力、講嘢唔清楚、或者暈到暈低，一定要即刻去急症室。」「你有冇嘢想問？」 | Safety-net for red flags; proper closure |
Uncovering the hidden agenda: The patient's real reason for coming today may not be the dizziness itself — it could be fear of stroke, anxiety about a relative who had a brain tumour, worry about losing their job, or medication side effects. Ask 「你今日特別嚟睇，係咪有啲嘢特別擔心？」early in ICE.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Clarify type | What do you mean by dizzy? Spinning? Faintness? Unsteadiness? | 「你話暈，係天旋地轉、定係想暈低、定係行路唔穩？」 | "Dizzy" is a non-specific term, especially true in Chinese — importance of clarification [1] | Vertigo → peripheral/central; Presyncope → cardiac/orthostatic; Disequilibrium → neuro/MSK |
| Onset & duration | When did it start? How long does each episode last? | 「幾時開始？每次維持幾耐？幾秒、幾分鐘、定幾個鐘？」 | Seconds = BPPV; hours = Ménière's; days = labyrinthitis; constant = central | BPPV (seconds), Ménière's (20min–hrs), labyrinthitis (days), central (persistent) |
| Triggers | Does head movement or position change bring it on? | 「轉頭或者瞓低起身會唔會特別暈？」 | Head-position-triggered = BPPV; BPPV is common but not all dizziness worsened by motion is BPPV [1] | BPPV; orthostatic hypotension |
| Hearing Sx | Any hearing loss, tinnitus, ear fullness? | 「有冇耳鳴？聽嘢差咗？耳仔有冇脹脹哋？」 | Triad of vertigo + hearing loss + tinnitus = Ménière's; unilateral SNHL = acoustic neuroma | Ménière's disease; acoustic neuroma |
| Central red flags | Any limb weakness, numbness, slurred speech, double vision, difficulty swallowing? | 「有冇手腳冇力、痺、講嘢唔清楚、嘢睇到兩個、吞嘢困難？」 | Most important to rule out central cause [1]; brainstem stroke features [3] | Posterior circulation stroke; brainstem lesion; MS |
| Headache | Any new/severe headache, especially at the back of the head? | 「有冇頭痛？特別係後尾枕嗰度？」 | Cerebellar haemorrhage/infarct presents with occipital headache + vertigo + ataxia [4] | Cerebellar stroke; posterior fossa mass |
| N/V, sweating | Any nausea, vomiting, sweating? | 「有冇作嘔、嘔、出冷汗？」 | Autonomic symptoms suggest peripheral vestibular cause [2]; also cerebellar haemorrhage [4] | Labyrinthitis; Ménière's; BPPV; also cerebellar lesion |
| Syncope/LOC | Have you actually fainted or lost consciousness? | 「有冇真係暈低過？冇咗知覺？」 | Differentiates syncope from vertigo/presyncope; patients may use "dizzy" for LOC [1] | Cardiac syncope; vasovagal; epilepsy |
| Cardiac Sx | Any palpitations, chest pain, SOB on exertion? | 「有冇心跳好快/亂、胸口痛、行路氣喘？」 | Arrhythmia causing presyncope/dizziness [5] | Arrhythmia; structural heart disease; HF |
| PMHx | Any chronic diseases? HTN, DM, heart disease, stroke? | 「有冇長期病？高血壓、糖尿、心臟病、中風？」 | HTN/DM = vascular RF for stroke; DM = hypoglycaemia; Parkinson's = orthostatic | Posterior circulation stroke; hypoglycaemia; drug-related |
| Drug Hx | What medications are you taking? Any new ones? | 「食緊咩藥？最近有冇轉藥或者加新藥？」 | Drugs are a masquerade — antihypertensives, carbidopa/levodopa cause orthostatic dizziness [6]; aminoglycosides = vestibulotoxic | Drug-induced dizziness/orthostatic hypotension |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Required field in CRF | — |
| Social / Occupation | What work do you do? Do you drive? Alcohol? | 「你做咩工作？有冇揸車？飲唔飲酒？」 | Driving risk if vertigo; alcohol = cerebellar/vestibular; occupational hazard (heights) | Alcohol-related cerebellar degeneration; safety issue |
| Psych screen | Any stress, worry, poor sleep, anxiety? | 「最近有冇壓力大、心情唔好、瞓唔着？」 | Anxiety/panic → hyperventilation → dizziness; depression = masquerade | Anxiety disorder; depression; psychogenic dizziness |
| Functional impact | How does the dizziness affect your daily life? | 「暈嘅時候影唔影響你日常生活？行街、做嘢、湊仔？」 | Social/functional domain for biopsychosocial model | — |
| FHx | Any family history of stroke, heart disease, deafness? | 「屋企人有冇中風、心臟病、耳聾？」 | Hereditary hearing loss; familial cardiac arrhythmia | — |
Case Report Form Answer Builder
Format: "Dizziness / Vertigo for [duration]"
Must capture:
- Type of dizziness (true vertigo vs presyncope vs disequilibrium)
- Onset (sudden vs gradual), duration of each episode, frequency
- Triggers (head position, standing up, stress)
- Associated symptoms (N/V, hearing loss, tinnitus, headache, focal neuro Sx, palpitations)
- Red flags screened (neuro deficits, LOC, headache)
- PMHx, DHx (HTN, DM, antiHT drugs, ototoxic drugs)
- Functional impact (work, driving, ADL)
Examples:
- "Patient wants to find out the cause of her recurrent dizziness"
- "Patient is worried the dizziness may be a sign of stroke"
- "Patient's dizziness is affecting her ability to work/care for family"
- Choose the ONE that best captures why the patient came TODAY (often a concern/fear rather than the symptom itself)
| Component | Likely Content | Exact Wording Example |
|---|---|---|
| Ideas | Patient thinks she may have low BP, anaemia, brain tumour | "Patient thinks the dizziness is caused by low blood pressure" |
| Concerns | Fear of stroke, brain tumour, falling, losing independence | "Patient is worried she may have a stroke like her mother" |
| Expectations | Wants a brain scan, blood test, medication to stop dizziness | "Patient expects referral for a brain scan to rule out serious causes" |
In a primary care FM station, the most likely diagnosis is usually BPPV (if positional, brief episodes, no hearing loss, no neuro signs) or acute vestibular neuritis (if continuous vertigo for days post-viral).
Minimum supporting evidence for BPPV:
- Episodic vertigo < 1 minute triggered by head position change
- No hearing loss, no tinnitus, no focal neurological signs
- Positive Dix-Hallpike test (torsional nystagmus with latency, fatigable)
| DDx | One Key Discriminator |
|---|---|
| Acute vestibular neuritis / labyrinthitis | Continuous vertigo lasting days, often post-viral; labyrinthitis = + hearing loss |
| Ménière's disease | Episodic vertigo (20 min–hours) + fluctuating hearing loss + tinnitus + aural fullness |
| Posterior circulation TIA / stroke | Sudden onset + focal neurological signs (diplopia, dysarthria, limb weakness, ataxia) |
(Adjust based on stem — if presyncope, consider orthostatic hypotension, cardiac arrhythmia, vasovagal)
| Domain | Problem |
|---|---|
| Biological | Recurrent vertigo causing nausea and functional limitation |
| Psychological | Anxiety/fear about having a stroke or serious brain disease |
| Social | Unable to work / risk of falls at home / unable to drive / carer burden on family |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| BPPV (most likely) | Positive Dix-Hallpike test — torsional nystagmus with latency (2–5s), crescendo-decrescendo, fatigable, with vertigo | Seat patient on bed → rapidly lie supine with head turned 45° and extended 30° below horizontal → observe eyes for 30s [9] | Pathognomonic for posterior canal BPPV; latency + fatigability distinguishes from central nystagmus |
| Vestibular neuritis | Positive head impulse test (corrective saccade on rapid head turn to affected side); horizontal spontaneous nystagmus beating AWAY from affected side | Rapid passive head turn → patient's eyes lose fixation → corrective saccade seen | Indicates peripheral vestibular hypofunction; abnormal HIT = peripheral |
| Ménière's disease | Sensorineural hearing loss on Weber/Rinne (low frequency initially) | Weber lateralises to UNAFFECTED ear; Rinne positive (AC > BC) bilaterally but reduced on affected side | SNHL confirms cochlear involvement; with episodic vertigo + tinnitus = Ménière's |
| Posterior circulation stroke | Cerebellar signs: truncal ataxia, failed tandem gait, nystagmus (direction-changing or vertical), dysmetria | Tandem (heel-to-toe) gait, finger-nose test, check nystagmus direction | Central nystagmus is direction-changing/vertical, non-fatigable, without latency; cerebellar signs = central lesion [1][3][4] |
| Orthostatic hypotension | Postural BP drop ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic on standing | BP lying → standing at 1 and 3 minutes | Confirms orthostatic mechanism; correlates with presyncope on standing |
| Cardiac arrhythmia | Irregular pulse / bradycardia / tachycardia on pulse palpation | Radial pulse for rate and rhythm | If irregular or abnormally slow/fast → supports arrhythmia; needs ECG |
Key Exam Point: Peripheral vs Central Vertigo
| Feature | Peripheral | Central |
|---|---|---|
| Nystagmus | Unidirectional, horizontal ± torsional, suppressed by fixation, latent, fatigable | Direction-changing or purely vertical, NOT suppressed by fixation, no latency |
| Hearing loss | May be present (Ménière's, labyrinthitis) | Usually absent |
| Neurological signs | Absent | Present (diplopia, dysarthria, dysphagia, limb weakness, ataxia) |
| Head impulse test | Abnormal (corrective saccade) | Normal (no saccade — brain lesion, NOT vestibular nerve) |
| Severity of vertigo | Often severe | May be mild |
| Imbalance | Mild-moderate, can walk | Severe, often cannot walk |
A normal head impulse test with nystagmus = think CENTRAL (the vestibular nerve is intact but the brain is not processing correctly) [1]
Top traps that lose marks:
- ❌ Not clarifying what the patient means by "dizzy" — This is the #1 error. Many patients use "暈" for presyncope, lightheadedness, unsteadiness, or even headache. You MUST differentiate [1].
- ❌ Assuming all positional dizziness = BPPV — "BPPV is common but not all dizziness worsened by motion is BPPV" [1]. Central lesions also worsen with movement.
- ❌ Missing central red flags — Always screen for: new headache, diplopia, dysarthria, dysphagia, focal weakness, ataxia, direction-changing nystagmus.
- ❌ Forgetting drug history — Antihypertensives, anticonvulsants, aminoglycosides, carbidopa/levodopa [6] are common causes.
- ❌ Not asking about hearing — Missing Ménière's or acoustic neuroma.
- ❌ Not eliciting ICE — Marks are specifically allocated for Ideas, Concerns, Expectations.
- ❌ Writing "dizziness" as the diagnosis — Must specify: BPPV / vestibular neuritis / Ménière's etc. "Most common diagnosis of true vertigo is 'vertigo NYD'" but try to narrow down [8].
Must-not-miss red flags → urgent referral/A&E:
- Acute vertigo + ANY focal neurological deficit → posterior circulation stroke until proven otherwise
- Sudden severe headache + vertigo + vomiting → cerebellar haemorrhage → emergency CT brain
- New onset vertigo + progressive unilateral hearing loss → acoustic neuroma → MRI
- Vertigo + LOC → consider cardiac cause → ECG, Holter
Shortest safe management/safety-net line:
「如果你突然手腳冇力、講嘢唔清楚、頭好痛、或者暈到暈低，一定要即刻打999去急症室。」 ("If you suddenly develop limb weakness, slurred speech, severe headache, or loss of consciousness, call 999 and go to A&E immediately.")
High Yield Summary
What to ASK:
- Clarify type of dizziness (vertigo vs presyncope vs disequilibrium) — this is your FIRST question
- Duration of each episode (seconds → BPPV; hours → Ménière's; days → neuritis; persistent → central)
- Central red flags: 5 D's — Diplopia, Dysarthria, Dysphagia, Drop attacks, focal Deficits
- Hearing symptoms (tinnitus, hearing loss, fullness)
- Drug history (antihypertensives, ototoxic drugs)
- ICE — especially concerns about stroke/tumour
What to WRITE on the CRF:
- Chief complaint: specify type (e.g., "episodic true vertigo for 2 weeks")
- Main RFC: the real reason they came today (often fear, not symptom)
- Most likely Dx: BPPV is most common in FM; support with positional trigger + brief duration + no hearing loss + Dix-Hallpike
- DDx: vestibular neuritis, Ménière's, posterior circulation TIA
- Biopsychosocial: vertigo (bio) + anxiety about stroke (psych) + unable to work/drive (social)
- Physical sign: Dix-Hallpike test for BPPV
What NOT to MISS:
- Central causes (stroke, cerebellar haemorrhage) — screen every patient
- Drug-induced dizziness — always check medications
- Hidden agenda — why TODAY?
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 221. Vertigo Peripheral and central.pdf (Slides 4, 5, 31) [2] Senior notes: Maksim Medicine Notes.pdf (p. 236 — Dizziness/Vertigo section) [3] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p. 1142 — Brainstem/Cerebellar stroke manifestations) [4] Lecture slides: Neurology- Introduction to CNS investigations and neurological emergencies.pdf (p. 12 — cerebellar haemorrhage case) [5] Senior notes: Ryan Ho Cardiology.pdf (p. 62–63 — Syncope/Arrhythmia) [6] AOS material: AOS - Geriatrics.pdf (p. 14–15 — Carbidopa/levodopa causing falls/dizziness) [7] Senior notes: Block A - Endocrine Data Interpretation.pdf (p. 2 — Hypoglycaemia differentials for dizziness) [8] Lecture slides: CFB (FM02) Introduction to common problems - Differentiating the normal from the abnormal.pdf (p. 35) [9] Lecture slides: MBBS IV Clinical Skills Session Ear and Nose 2025 (1).pdf (p. 26 — Dix-Hallpike test)
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