Dizziness

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Contributing factorsChoose any

Red flags presentChoose any

Red flags absentChoose any

ExamChoose one

Orthostatic vital signsChoose one

AssessmentChoose one

WorkupChoose one

LabsChoose any

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CounselingNot in the note with these choices

Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Dizziness
• Lightheadedness on standing or with prolonged standing, consistent with orthostatic or vasovagal symptoms
• No symptoms with exercise, fainting, chest pain or a racing heartbeat, family history of early sudden cardiac death, severe or worsening headaches, focal neurologic symptoms, or hearing loss
• Neurologic and cardiopulmonary exam reassuring, with normal gait and eye movements
• Dizziness most consistent with a benign cause today
• Further workup deferred given a typical history and reassuring exam
• Counseled on drinking water throughout the day, regular meals, and standing up slowly
• Cardiology or neurology referral if symptoms recur or worsen
• Follow up if worsening or not improving

Lightheadedness in children and teens most often comes from a brief drop in blood flow to the brain with standing, heat, or not drinking and eating enough, and it is not dangerous. Recommended supportive care with an emphasis on drinking water throughout the day, regular meals, standing up slowly, and sitting or lying down at the first warning signs. Return precautions given including fainting, symptoms with exercise, chest pain, a racing heartbeat, trouble breathing, a severe headache, weakness or trouble walking, vomiting that keeps happening, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Lightheadedness vs vertigo types (benign paroxysmal vertigo, vestibular migraine, BPPV, vestibular neuritis)
Contributing factors
Red flags present or absent (exercise, fainting, chest pain or racing heart, family history, severe headache, neuro deficits, hearing loss)
Orthostatic vital signs
"EKG or labs to be considered"
Hydration, meals, slow position changes
Salt if orthostatic
Caffeine, warning-sign position, migraine measures
Cardiology, neurology, ENT referral

Return precautions in the template

faintingsymptoms with exercisechest paina racing heartbeattrouble breathinga severe headacheweakness or trouble walkingvomiting that keeps happening

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.