History of Giddiness (Dizziness)

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1. Define the Symptom Character

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2. Timing

• Onset: Sudden or gradual?
• Duration of each episode: Seconds → BPPV; Minutes → TIA or Meniere's; Hours → Meniere's disease; Days/persistent → Vestibular neuritis, central cause
• Pattern: Single episode vs. recurrent episodes vs. chronic/constant

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3. Triggers

• Positional change (lying down, rolling over, looking up): BPPV
• Standing up: Orthostatic hypotension
• Head movement: Vestibular origin
• Valsalva / pressure: Perilymph fistula, superior semicircular canal dehiscence
• Loud sounds (Tullio phenomenon): Canal dehiscence
• Stress / anxiety / hyperventilation: Psychogenic
• Eating / fasting / medications: Metabolic/drug-induced

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4. Associated Symptoms

Peripheral vestibular (ask for):

• Tinnitus (ringing in ears)
• Hearing loss (unilateral → Meniere's, acoustic neuroma)
• Aural fullness / pressure
• Nausea and vomiting

Central vestibular / serious (red flags — ask specifically):

• Diplopia, dysarthria, dysphagia → brainstem
• Headache (especially occipital, sudden "thunderclap") → cerebellar haemorrhage, posterior fossa tumour
• Limb weakness or numbness
• Facial numbness or asymmetry
• Ataxia / falls

Cardiovascular:

• Palpitations → arrhythmia
• Chest pain
• Syncope or loss of consciousness

Other:

• Visual disturbance (aura) → migraine-associated vertigo (vestibular migraine)
• Headache (vestibular migraine is the most common cause of episodic vertigo in women)

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5. Past Medical History

• Hypertension, diabetes, hyperlipidaemia, atrial fibrillation → vascular/TIA risk
• Migraine history
• Previous ear surgery or infections
• Head trauma (BPPV can be post-traumatic)
• Autoimmune disorders (e.g., MS)

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6. Drug History

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7. Family History

• Neurofibromatosis type 2 (bilateral acoustic neuromas)
• Migraine
• Cardiac arrhythmias (e.g., long QT syndrome)

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8. Social History

• Alcohol (acute intoxication, chronic cerebellar degeneration)
• Occupation (noise exposure → cochlear damage)
• Driving / fall risk (important for safety counselling)
• Anxiety / panic disorder

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Summary: The TiTrATE Framework (Timing, Triggers, Associated symptoms)

1. Timing — duration and pattern of episodes
2. Triggers — what brings it on
3. Associated symptoms — ear, neurological, cardiovascular
4. Treatment response — any prior episodes, what helped/worsened
5. Effect on function — falls, driving, occupational impact

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Red Flag Features Requiring Urgent Investigation

• New headache + dizziness
• Focal neurological signs (diplopia, dysarthria, ataxia, weakness)
• Sudden onset ("worst of life") suggesting cerebellar haemorrhage
• Age >60 with first episode + vascular risk factors → TIA/posterior circulation stroke
• Hearing loss that is rapidly progressive or asymmetric without explanation

History of Loss of Consciousness (LOC)

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1. Clarify the Event

• Was there complete loss of consciousness or just near-LOC (pre-syncope)?
• Was there loss of postural tone (did they fall/slump)?
• Was there amnesia for the event?
• How long did the episode last?

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2. Before the Episode (Pre-ictal / Pre-syncopal Phase)

Prodrome / Warning Symptoms

Precipitating Factors (Ask specifically)

• Emotional stress, pain, prolonged standing, heat, crowded place → Vasovagal
• Standing up from lying/sitting → Orthostatic hypotension
• Micturition, defaecation, coughing, swallowing → Situational syncope
• Exertion → Cardiac outflow obstruction (HOCM, aortic stenosis), arrhythmia, PE
• Head turning / neck pressure → Carotid sinus hypersensitivity
• During sleep or supine → Cardiac arrhythmia (high-risk feature)
• Fasting, alcohol, sleep deprivation → Seizure threshold reduction

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3. During the Episode (Eyewitness Account — Critical)

Per Harrison's (p. 712): myoclonic jerks occur in up to 90% of syncopal episodes and must not be mistaken for seizure.

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4. After the Episode (Post-ictal Phase)

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5. Past Medical & Relevant History

• Cardiac history: IHD, cardiomyopathy, valvular disease, congenital heart disease, prior arrhythmia
• Neurological: prior seizures, epilepsy, head trauma, stroke, brain tumour
• Metabolic: diabetes (hypoglycaemia), Addison's disease, uraemia, hepatic failure
• Psychiatric: anxiety, panic disorder, dissociative episodes (psychogenic non-epileptic attacks — PNEA)
• Previous similar episodes — age of first episode, frequency, prior investigation

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6. Drug & Substance History

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7. Family History

• Sudden unexplained death in a young family member → channelopathy (Long QT, Brugada, CPVT)
• Epilepsy
• Hypertrophic cardiomyopathy (HOCM)

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8. Social History

• Alcohol and recreational drug use
• Occupation (driving, operating machinery — safety implications)
• Witnessed by anyone?
• Falls / injuries sustained

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Summary Framework: The 3-Phase Approach

BEFORE          →    DURING          →    AFTER
(Prodrome)           (Eyewitness)         (Recovery)
Triggers             Movements            Confusion duration
Warnings             Duration             Headache / myalgia
Position             Colour               Orientation
                     Incontinence         Todd's paresis

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Red Flag Features Requiring Urgent Assessment

• LOC during exertion
• LOC while supine or during sleep
• Sudden palpitations immediately preceding LOC
• Chest pain, dyspnoea, or abdominal pain before LOC
• New headache before LOC
• Severe structural or coronary artery disease
• No prodrome in a patient with cardiac history
• First seizure in an adult
• Focal neurological deficit after event

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Key Differentials at a Glance

History of Breathlessness (Dyspnoea)

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1. Characterise the Symptom

• "Does it feel like you can't get enough air in?"
• "Does your chest feel tight?"
• "Do you feel like you have to work hard to breathe?"

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2. Onset and Duration

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3. Severity

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4. Timing and Pattern

• Exertional vs. rest: exertional → cardiac or respiratory; at rest → severe disease or psychogenic
• Nocturnal:
  • Orthopnoea (breathless lying flat, relieved sitting up) → left heart failure, bilateral pleural effusions, diaphragmatic paralysis
  • Paroxysmal Nocturnal Dyspnoea (PND) (wakes from sleep, relieved after sitting upright for minutes) → left ventricular failure
  • Nocturnal wheeze → asthma (classically 2–4 am)
• Positional:
  • Trepopnoea (breathless lying on one side) → unilateral pleural effusion, unilateral lung disease
  • Platypnoea (breathless sitting up, relieved lying flat) → hepatopulmonary syndrome, ASD with right-to-left shunt
• Episodic vs. constant: episodic → asthma, PE, cardiac arrhythmia; constant → COPD, ILD, heart failure

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5. Aggravating and Relieving Factors

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6. Associated Symptoms

Respiratory:

• Cough — productive (COPD, pneumonia, bronchiectasis), dry (ILD, ACE inhibitor, cardiac failure)
• Wheeze — asthma, COPD, cardiac asthma
• Stridor — upper airway obstruction (foreign body, anaphylaxis, epiglottitis)
• Haemoptysis — PE, malignancy, TB, bronchiectasis, mitral stenosis
• Sputum — colour, quantity, consistency

Cardiac:

• Chest pain — ischaemia (angina/ACS), pleuritic pain (PE, pneumonia, pericarditis)
• Palpitations — arrhythmia (AF can precipitate acute pulmonary oedema)
• Ankle swelling — right or biventricular heart failure
• Orthopnoea / PND (as above)

Systemic:

• Fever / chills → infection (pneumonia, sepsis)
• Weight loss / night sweats → malignancy, TB
• Fatigue → anaemia, heart failure, malignancy
• Leg swelling / calf pain → DVT → PE

Neurological / Muscular:

• Limb weakness, bulbar symptoms → neuromuscular (MND, Guillain-Barré, myasthenia)

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7. Past Medical History

• Cardiac: IHD, heart failure, hypertension, valvular disease, AF, congenital heart disease
• Respiratory: asthma, COPD, TB, previous pneumonia, pneumothorax, ILD
• Thromboembolic: prior DVT/PE, thrombophilia
• Metabolic: anaemia, thyroid disease (hyperthyroidism, hypothyroidism with pleural effusion), renal failure, liver disease (hepatopulmonary syndrome, ascites)
• Malignancy: primary lung, lymphoma, pleural mesothelioma
• Immunosuppression: HIV (PCP, TB), post-transplant

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8. Drug History

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9. Social History

• Smoking: pack-year history → COPD, lung cancer, IHD
• Occupational exposure:

• Travel: TB (endemic area), coccidioidomycosis, histoplasmosis
• Pets: bird droppings → hypersensitivity pneumonitis
• Alcohol: aspiration pneumonia, alcoholic cardiomyopathy
• Illicit drugs: cocaine (pulmonary haemorrhage), IV drugs (septic emboli)

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10. Family History

• Asthma / atopy
• Alpha-1 antitrypsin deficiency (early COPD, non-smoker)
• Pulmonary hypertension (heritable PAH — BMPR2 mutation)
• Cystic fibrosis
• Cardiomyopathy

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Summary: SOCRATES + Contextual Framework

S — Site/Character     What does the breathlessness feel like?
O — Onset              Sudden / gradual / episodic?
C — Character          Exertional / nocturnal / positional?
R — Radiation          —
A — Associated Sx      Cough, wheeze, chest pain, oedema, haemoptysis
T — Timing/Pattern     Constant / episodic / progressive?
E — Exacerbating Sx    Exercise, allergens, lying flat, occupation
S — Severity           MRC grade / NYHA class / baseline function

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Key Differentials at a Glance

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Red Flags Requiring Urgent Assessment

• Sudden onset dyspnoea at rest
• Haemoptysis
• Stridor
• Cyanosis
• Oxygen saturation <92%
• Associated chest pain
• Dyspnoea while supine or during sleep (PND)
• Dyspnoea on exertion with syncope (pulmonary hypertension, HOCM, aortic stenosis)
• Rapidly progressive dyspnoea over days