Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Describe the dizziness/vertigo:
Type of sensation (dizziness, lightheadedness, spinning sensation)
Frequency and duration of episodes
Precipitating factors (head movement, position changes, certain activities)
Associated symptoms (nausea, vomiting, tinnitus, hearing loss, imbalance)
Impact on daily activities
Inquire about recent illnesses, injuries, or new medications.
Explore history of migraines, head trauma, or ear problems.
Objective:
Vital Signs: Include heart rate, blood pressure (check for orthostatic changes – measure BP lying and standing).
Physical Exam:
General: Assess for signs of acute illness (fever, pallor).
Neurologic:
Mental status: Alertness, orientation, cognitive function.
Cranial nerves: Test for nystagmus (involuntary eye movements).
Motor exam: Muscle strength, coordination, gait.
Romberg test: Balance with eyes closed and feet together.
Cardiovascular: Evaluate for orthostatic hypotension (decrease in BP with standing).
ENT (ear, nose, throat): Look for signs of inner ear inflammation (otitis media).
Assessment:
Dizziness and/or vertigo.
Differentiate between true vertigo (spinning sensation) and other forms of dizziness.
Consider potential causes based on history and exam:
Inner ear disorders: Benign paroxysmal positional vertigo (BPPV), Meniere’s disease, labyrinthitis.
Migraine-associated vertigo: May occur with or without headache.
Orthostatic hypotension: Blood pressure drop upon standing.
Neurologic conditions: Stroke, transient ischemic attack (TIA), multiple sclerosis.
Medication side effects: Certain medications can cause dizziness.
Cervicogenic dizziness: Originates from neck dysfunction.
Anxiety or panic disorder: Can manifest as dizziness.
Plan:
Based on the suspected cause:
Inner ear disorders: Specific maneuvers for BPPV, medications for Meniere’s disease or labyrinthitis.
Migraine-associated vertigo: Migraine prophylaxis medications.
Orthostatic hypotension: Address underlying cause (dehydration, medications), increase fluid intake, compression stockings.
Neurologic conditions: Imaging studies (MRI) and referral to a neurologist.
Medication side effects: Consider medication adjustments.
Cervicogenic dizziness: Physical therapy for neck strengthening and mobility exercises.
Anxiety or panic disorder: Cognitive behavioral therapy (CBT) or medications.
General Measures:
Stay hydrated.
Avoid triggers identified (e.g., sudden head movements).
Balance exercises if appropriate.
Follow-up:
Schedule revisit to monitor response to treatment and reassess symptoms.
Consider referral to an ENT specialist, neurologist, or physical therapist as needed.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding the type of dizziness, associated symptoms, potential causes, and treatment plan.