Common Symptoms
Dizziness / Syncope
The first task with dizziness or syncope is to separate vertigo, presyncope, syncope, and disequilibrium — they have very different workups. Cardiac syncope is deadly, and missing it is one of the most common high-liability outpatient errors. This page walks through can't-miss diagnoses (cardiac syncope from arrhythmia, structural heart disease, severe aortic stenosis, pulmonary embolism, posterior circulation stroke, GI bleed, aortic dissection, hypoglycemia, sepsis, severe anemia), red flags including syncope without prodrome or during exertion, the minimum safe first-pass workup (focused history, orthostatic vitals, ECG on every syncope, neuro exam, HEENT for BPPV, POC glucose), risk stratification, outpatient management of benign causes, escalation criteria, documentation, and return precautions. Written for NPs, PAs, and MDs in outpatient practice.
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Common Symptoms
Dizziness / Syncope
Why this symptom matters
Most dizziness is benign, but cardiac syncope and posterior-circulation stroke can present subtly. AAFP guidance: history, exam, orthostatics, and ECG cover most of the diagnostic yield. Reflex labs and imaging rarely help.
What must I not miss first?
- Cardiac syncope (arrhythmia, structural heart disease, aortic stenosis)
- Posterior-circulation stroke / TIA
- Pulmonary embolism (presenting as syncope)
- GI bleed / occult hemorrhage
- Ectopic pregnancy in women of reproductive age
- Severe dehydration / sepsis
- Hypoglycemia, severe electrolyte derangement
Red flags — escalate or work up urgently
- Exertional syncope or syncope without prodrome
- Chest pain, palpitations, or known cardiac disease
- Family history of sudden cardiac death
- Abnormal ECG (long QT, Brugada pattern, AV block, ischemia)
- Focal neurologic deficit, diplopia, dysarthria, ataxia
- Anticoagulation + fall + headache
- Hypotension, melena, or anemia
Minimum safe first-pass workup
- Targeted history: prodrome, position, triggers, medications, prior episodes
- Orthostatic vital signs (lying, sitting, standing)
- ECG in nearly all true syncope
- Glucose if any AMS
- Pregnancy test in reproductive-age women
- Targeted labs only if history supports them — not reflex panels
- HINTS exam if continuous vertigo (not for episodic)
What can usually be managed outpatient
- BPPV with classic triggers and positive Dix-Hallpike — Epley in office
- Vasovagal syncope with clear prodrome and benign workup
- Orthostatic dizziness from medication or volume depletion that responds to interventions
- Peripheral vestibular dysfunction with reassuring HINTS
When to escalate to ED / higher level of care
- Any suspicion of cardiac syncope or stroke
- Syncope with injury, head trauma on anticoagulation
- Hemodynamic instability or significant orthostatic drop without explanation
- Continuous vertigo with central features (HINTS positive)
What to document when the diagnosis is still uncertain
- Distinguish presyncope vs syncope vs vertigo vs disequilibrium
- Prodrome, position, exertion, witnesses, post-event state
- Orthostatic vitals and ECG findings
- Cardiac, neurologic, and bleeding causes considered
- Why no imaging if none ordered
Safety-net & return precautions to give
- Return or call 911 for new chest pain, palpitations, weakness on one side, slurred speech, vision loss, severe headache, fainting, or black/bloody stools.
- Don't drive until cleared.
- Follow up in [X days] for ECG/Holter results or cardiology referral.
Educational guidance for clinicians. Not a substitute for clinical judgment. Always individualize to the patient and your local resources.
Evidence sources
- · AHA/ACC/HRS Syncope Guideline 2017
- · AAO-HNS BPPV Guideline 2017
Review status
Last reviewed: 2026-04
Reviewed by the MyClinicianGuide editorial team. Cadence: annual.
Educational reference for licensed clinicians (NP, PA, MD, DO). Not a substitute for clinical judgment, institutional protocols, or specialty consultation. Apply in context of the full clinical picture, patient goals, and current standards of care. See About AI guidance for AI-related limitations.
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