Clinical Commander

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symptom.vertigo.v1

Vertigo (acute / recurrent)

symptomacutesubacuteundifferentiatedadultacuteoutpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym deepening pass (2026-05-14) — full §5.5 contract depth. Pattern peers: symptom.chest_pain.ed_undifferentiated.v1 (be7b7d2f) + neuro.ischaemic-stroke.v1 (a738ab2a). Engine scope: triage + risk-stratification + disposition for the dizzy / vertiginous patient (ED + outpatient). Downstream confirmed diagnoses route to neuro.ischaemic-stroke.v1 (HINTS central pattern, vertebral artery dissection, cerebellar hemorrhage/infarct) and neuro.migraine.core.v1 (Bárány 2015 vestibular migraine criteria). Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors by setting) lives in companion depth bundle _briefs/symptom.vertigo.v1.depth.md — schema has no first-class likelihood-ratio field. 5 setting playbooks (home, ed, icu, inpatient, outpatient). 12 severity triggers (≥6 per spec): hints_central_pattern + hints_peripheral_pattern + bppv_posterior_canal_dix_hallpike + bppv_horizontal_canal_supine_roll + meniere_triad + vestibular_migraine + sudden_snhl_with_vertigo + vertebral_artery_dissection + cerebellar_hemorrhage_infarct + persistent_vertigo_with_dehydration + elderly_on_meclizine_or_benzo + meniere_progressive_hearing_loss. 2 sibling differentiation rows (neuro.ischaemic-stroke.v1 + neuro.migraine.core.v1) — both verified to exist in ALL_DOSSIERS registry. Additional look-alikes (syncope/presyncope, orthostatic, panic, cerebellar mass) captured as pivots in depth bundle. Schema-blocked items surfaced: HINTS+ codifier, Dix-Hallpike codifier, supine-roll codifier, Epley step-tracker, GUSS (cross-engine) — none in clinical-tools-registry.ts; cross-shard tickets emitted to shard-0. Modern view captured: meclizine + benzodiazepines are short-course only (delay vestibular compensation, AGS Beers 2023 in elderly). Epley canalith repositioning + vestibular rehab are first-line (AAO-HNS 2017 Class I; Cochrane 2014). PMIDs (9): Newman-Toker HINTS 2009 (19762709), HINTS+ 2013 (24127701), AAO-HNS BPPV 2017 (28248609), AAO-HNS Meniere 2020 (32267799), Bárány 2015 (23532572), AAO-HNS SSNHL 2019 (31369359), Cochrane Vestibular Rehab 2014 (24492332), Strupp NEJM 2004 (15269315), AHA/ASA Stroke 2021 (34024117). All marked NEEDS_SOURCE_REVIEW per shard convention.

Entry points (7)

  • symptom
    Acute continuous vertigo + nausea + nystagmus + gait unsteadiness ≥24 h (Newman-Toker Stroke 2009 PMID 19762709 — HINTS+ indication)
    acute_vestibular_syndrome
  • symptom
    Brief vertigo provoked by head position change (AAO-HNS BPPV 2017 PMID 28248609 — Dix-Hallpike indication)
    positional_vertigo
  • symptom
    Recurrent spontaneous vertigo episodes — Meniere (AAO-HNS 2020 PMID 32267799) / vestibular migraine (Bárány 2015 PMID 23532572)
    recurrent_episodic_vertigo
  • symptom
    Vertigo with hearing loss / tinnitus / aural fullness (AAO-HNS 2020 Meniere criteria)
    vertigo_plus_hearing_loss
  • symptom
    Sudden SNHL >30 dB ≥3 contiguous frequencies within 72 h + vertigo — AICA infarct vs labyrinthitis vs Meniere (AAO-HNS 2019 SSNHL CPG PMID 31369359)
    sudden_sensorineural_hearing_loss_with_vertigo
  • symptom
    Vertigo with diplopia / dysarthria / ataxia / weakness / sensory deficit — central concern (AHA/ASA 2021 PMID 34024117)
    vertigo_with_neuro_signs
  • symptom
    Vertigo + acute neck pain after trauma / chiropractic — vertebral artery dissection (AHA/ASA 2021)
    vertigo_with_neck_pain

Required inputs (20)

  • agerequired
    demographic • used at CONTEXT
    Age >60 = higher prior for posterior circulation stroke (AHA/ASA 2021 PMID 34024117) and BPPV (AAO-HNS 2017 PMID 28248609)
  • sexrequired
    demographic • used at CONTEXT
    Vestibular migraine and Meniere skew female (Bárány 2015 PMID 23532572; AAO-HNS 2020 PMID 32267799)
  • sbprequired
    vital • used at CONTEXT
    Orthostatic vitals to differentiate presyncope from true vertigo; supine + standing measurements (AAN 2024)
  • hrrequired
    vital • used at CONTEXT
    Orthostatic delta; bradyarrhythmia and AF mimic vertigo (AAN 2024); AF screen if cryptogenic posterior infarct (CRYSTAL-AF Sanna NEJM 2014)
  • symptom_durationrequired
    symptom • used at FRAME
    Seconds (BPPV — AAO-HNS 2017) vs minutes-hours (vestibular migraine — Bárány 2015) vs hours-days (Meniere — AAO-HNS 2020 / neuritis / stroke)
  • positional_triggerrequired
    symptom • used at FRAME
    Position-evoked = BPPV until proven otherwise; latency 1-5 s after position change with torsional up-beating nystagmus (AAO-HNS 2017 PMID 28248609)
  • hearing_changerequired
    symptom • used at CONTEXT
    Sudden SNHL + vertigo = AICA stroke vs Meniere (AAO-HNS 2020) vs labyrinthitis vs SSNHL (AAO-HNS 2019 PMID 31369359)
  • tinnitus_or_aural_fullness
    symptom • used at CONTEXT
    Meniere triad component (AAO-HNS 2020 PMID 32267799); cochleovestibular pattern
  • headache_or_neck_painrequired
    symptom • used at RED_FLAGS
    Vertebral artery dissection — neck pain + posterior circulation deficit, often after trauma or chiropractic manipulation (AHA/ASA 2021 PMID 34024117)
  • gait_unsteadinessrequired
    symptom • used at RED_FLAGS
    Truncal ataxia disproportionate to vertigo = central lesion / cerebellar pathology (Newman-Toker Stroke 2009 PMID 19762709)
  • focal_neuro_deficitrequired
    symptom • used at RED_FLAGS
    Diplopia, dysarthria, hemiparesis, hemisensory loss, dysphagia → central until proven otherwise (AHA/ASA 2021)
  • vascular_risk_factorsrequired
    history • used at CONTEXT
    HTN, DM, AF, smoking, prior stroke/TIA, hyperlipidemia shifts prior to central (AHA/ASA 2021 PMID 34024117)
  • migraine_history
    history • used at CONTEXT
    Vestibular migraine criterion (Bárány Society 2015 PMID 23532572) — ≥5 episodes + ≥50% with migraine features
  • recent_uri
    history • used at CONTEXT
    Vestibular neuritis post-URI (1-2 wk latency); labyrinthitis if + hearing loss (Strupp NEJM 2004 PMID 15269315)
  • recent_neck_trauma_or_manipulation
    history • used at RED_FLAGS
    Vertebral artery dissection precipitant (AHA/ASA 2021)
  • current_medsrequired
    medication • used at CONTEXT
    Aminoglycosides, loop diuretics, cisplatin, salicylates (ototoxic — AAO-HNS 2024); antihypertensives (orthostatic); benzodiazepines / meclizine (AGS Beers 2023)
  • mri_brain_dwi
    imaging • used at BRANCHING_WORKUP
    MRI DWI confirms posterior circulation infarct — INSENSITIVE in first 24-48 h (Newman-Toker Stroke 2009 PMID 19762709; HINTS+ outperforms early MRI: HINTS sens 97% vs MRI <50% at <48 h)
  • cta_or_mra_neck
    imaging • used at BRANCHING_WORKUP
    STAT CTA/MRA neck for vertebral artery dissection (AHA/ASA 2021)
  • audiometry
    imaging • used at BRANCHING_WORKUP
    Sensorineural pattern in Meniere (AAO-HNS 2020 PMID 32267799); sudden SNHL needs urgent steroid (AAO-HNS 2019 SSNHL PMID 31369359)
  • fingerstick_glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia / hyperglycemia mimics; correct before treating as code stroke

12-phase flow (12)

  1. 1FRAME
    Confirm vertigo (illusion of motion) vs presyncope / disequilibrium / lightheadedness (AAN 2024); episodic vs continuous; positional vs spontaneous; first vs recurrent
    inputs: symptom_duration, positional_trigger
    advance: vertigo character + temporal pattern established
  2. 2ENTRY
    Acute vestibular syndrome (Newman-Toker 2009) vs recurrent positional (AAO-HNS 2017) vs Meniere triad (AAO-HNS 2020) vs post-URI vestibular neuritis vs sudden SNHL+vertigo (AAO-HNS 2019)
    inputs: age
    advance: entry pattern recognized
  3. 3CONTEXT
    Duration, triggers, hearing change, tinnitus, headache, vascular risks (AHA/ASA 2021), ototoxic meds (AAO-HNS 2024), recent URI, migraine history (Bárány 2015), orthostatic vitals
    inputs: sex, sbp, hr, hearing_change, vascular_risk_factors, current_meds, migraine_history, recent_uri
    advance: context complete + life-threat screen run
  4. 4RED_FLAGS
    HINTS central pattern — normal head impulse + direction-changing nystagmus + skew deviation (Newman-Toker Stroke 2009 PMID 19762709); neck pain + posterior deficit → vertebral dissection (AHA/ASA 2021); sudden SNHL (AAO-HNS 2019); focal neuro deficit; truncal ataxia disproportionate to vertigo (cerebellar)
    inputs: headache_or_neck_pain, gait_unsteadiness, focal_neuro_deficit
    actions: workup.acute_stroke, workup.ssnhl
    advance: no central red flags OR routed to stroke pathway
  5. 5INITIAL_WORKUP
    Bedside HINTS+ for acute vestibular syndrome (Newman-Toker 2009; HINTS+ adds finger-rub hearing — Kattah 2009); Dix-Hallpike for posterior-canal BPPV (AAO-HNS 2017); supine roll for horizontal-canal BPPV; orthostatic vitals; fingerstick glucose; ECG if presyncope or AF risk
    inputs: fingerstick_glucose
    actions: workup.vertigo
    advance: bedside vestibular exam complete
  6. 6BRANCHING_WORKUP
    MRI brain DWI + MRA posterior circulation if HINTS central pattern or persistent vertigo with vascular RFs (AAN 2024); CTA neck if dissection suspicion (AHA/ASA 2021); ENT for SSNHL (AAO-HNS 2019) / Meniere (AAO-HNS 2020); audiometry; tilt-table if recurrent presyncope
    inputs: mri_brain_dwi, cta_or_mra_neck, audiometry
    advance: imaging or specialist evaluation done
  7. 7DIFFERENTIAL
    BPPV (AAO-HNS 2017 — ~20-30% of ED vertigo) / vestibular neuritis (~10-15%) / Meniere (AAO-HNS 2020) / labyrinthitis / posterior circulation stroke (AHA/ASA 2021 — ~3-5% ED / up to 25% ED-AVS) / vestibular migraine (Bárány 2015) / cerebellar lesion / ototoxicity / orthostatic / SSNHL+vertigo (AAO-HNS 2019) / vertebral dissection
    advance: differential ranked with pre-test priors documented
  8. 8RISK_STRATIFICATION
    ABCD2 + posterior circulation features if TIA suspected; NIHSS underweights posterior circulation (NICE 2024); HINTS+ sensitivity > early MRI for posterior stroke (Newman-Toker Stroke 2009 — sens 97% vs MRI 83% at <48 h)
    inputs: age, vascular_risk_factors
    actions: calc.abcd2
    advance: risk score documented
  9. 9TREATMENT
    Epley for posterior canal BPPV (AAO-HNS 2017 Class I >70% single-session success); Gufoni / Lempert for horizontal canal; vestibular rehab (AAO-HNS 2017 strong recommendation; Cochrane 2014 PMID 24492332); short-course meclizine/benzo only (AGS Beers 2023); prednisolone for vestibular neuritis (Strupp NEJM 2004 PMID 15269315); high-dose oral steroid for SSNHL (AAO-HNS 2019); betahistine + low Na for Meniere (AAO-HNS 2020); treat stroke if central
    advance: targeted therapy initiated
  10. 10DISPOSITION
    Discharge with follow-up for peripheral; admit for central or undifferentiated severe; ICU for cerebellar hemorrhage/infarct with brainstem compression; ENT urgent for SSNHL (AAO-HNS 2019)
    actions: protocol.acute_ischemic_stroke.v1
    advance: disposition documented
  11. 11MONITORING
    Symptom diary, recurrence, audiometry follow-up if Meniere (AAO-HNS 2020); vestibular rehab progress; fall risk if elderly (AGS Beers 2023)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Vestibular rehab referral (AAO-HNS 2017 strong recommendation; Cochrane 2014); audiology q6-12 mo for Meniere; neurology if vestibular migraine (Bárány 2015 — route to neuro.migraine.core.v1); ENT for refractory Meniere
    advance: referrals scheduled