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Dizziness on the CCFP exam
8 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 8 key features for Dizziness. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 8
Danger first
Before you call dizziness harmless, look for a dangerous heart or brain cause.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
An older man with atrial fibrillation has new dizzy spells. Expect a short menu: you pick several causes to look for.
Pick the dangerous causes to look for.
Common mistakes
Calling it an inner-ear problem because he once had positional vertigo. That misses his rhythm: atrial fibrillation running too slow or too fast can cause spells.
Approach
- Heart causes come first: an abnormal rhythm, a heart attack, a tight aortic valve. Check the pulse and get an ECG.
- Brain causes: a stroke at the back of the brain, a bleed, or multiple sclerosis in a younger adult.
- Ask about warning signs: chest pain, a racing heart, fainting during effort, new headache, double vision, slurred speech, weakness, trouble walking.
- With a simple faint and a normal neuro exam, do not routinely order MRI, carotid ultrasound or EEG. A CT head depends on the high-risk features under Who to scan.
Key feature 2 of 8
Name the type
Use the story to sort spinning from near-fainting from blacking out.
CFPC skill Clinical reasoningPhase History
On the exam
An 81-year-old was found on the bathroom floor after days of dizzy spells. Expect a short menu of questions to ask.
Pick the questions that sort the type.
Common mistakes
Asking first about hearing loss, migraine or mood. Those help once you know the type. They cannot tell spinning from near-fainting.
Approach
- Ask the patient to describe it without the word dizzy.
- Spinning or tilting is vertigo. Feeling about to black out is presyncope. Losing consciousness is syncope.
- Ask what brings it on: standing up, turning the head, effort, or nothing at all.
- Ask how long it lasts, and whether it is constant or comes in spells.
- Ask what came with it: a racing heart, chest pain, sweating, a fall, an injury, someone who saw it.
- Unsteady walking with no spells is imbalance, a fourth type. Anxiety or low mood is a cause you reach last, once the type is clear.
| Type | It feels like | Think of |
|---|---|---|
| Vertigo | The room spins or tilts | Inner ear: positional vertigo, vestibular neuritis, Ménière disease. Brain: stroke, multiple sclerosis. |
| Presyncope | About to faint; vision greys out | Low pressure on standing, drugs, bleeding, an abnormal rhythm |
| Syncope | Blacked out, then woke up | Reflex faint, low pressure on standing, a heart rhythm or valve problem |
| Imbalance | Unsteady on the feet, no spells | Nerve damage in the feet, poor vision, Parkinson disease, drugs |
Key feature 3 of 8
Lying and standing
Take blood pressure and pulse lying down, then again sitting or standing.
CFPC skill Clinical reasoning, procedure skillsPhase Physical
On the exam
A woman with a spinal cord injury feels faint when she sits up. Expect a short menu of exam steps.
Pick the exam steps that fit her.
Common mistakes
Trying to stand her up by habit. She cannot stand, so it risks a fall and measures nothing. A test for positional vertigo is wrong too.
Approach
- Measure blood pressure and pulse after a few minutes lying down. Repeat after a few minutes standing.
- A clear fall in pressure, or symptoms that return on standing, means low blood pressure on standing (orthostatic hypotension).
- If the patient cannot stand, measure lying, then sitting up with the legs down.
- A low pressure with a fast pulse points to fluid or blood loss.
- A beta-blocker can hide the pulse rise. Do not let a calm pulse reassure you.
- One normal reading does not rule it out when the story fits. Repeat it.
Key feature 4 of 8
Neuro exam
Examine the nervous system closely for signs that the brain is the cause.
CFPC skill Clinical reasoning, procedure skillsPhase Physical, hypothesis generationSources Choosing Wisely Canada
On the exam
Constant spinning since yesterday, with vomiting. Expect a short menu of exam steps to do now.
Pick the exam steps that find a stroke.
Common mistakes
Calling it vestibular neuritis (a viral inflammation of the balance nerve) after a normal arm and leg exam. A stroke at the back of the brain can spare the limbs, so check the eyes, the head impulse and walking.
Approach
- Check the eyes for nystagmus (jerking eye movements), then speech, face, strength, coordination and walking.
- Not able to walk without help, double vision or slurred speech points to the brain.
- In constant spinning with nystagmus, a trained examiner can use the HINTS exam to tell stroke from vestibular neuritis.
- HINTS means three bedside checks: the head impulse, the type of nystagmus, and a cover test for vertical eye misalignment.
- Do not use HINTS in brief spells or near-faints. Its result means nothing there.
- Brief spinning on lying down, rolling over or looking up: do a Dix-Hallpike test. Lie the patient back quickly, head turned, and watch the eyes. Do an Epley manoeuvre (head moves that shift the loose ear crystals) only if the test is positive.
- Where a deficit is old, such as below a spinal cord injury, look for a change from baseline.
Key feature 5 of 8
Dizzy and hypotensive
When a dizzy patient has low blood pressure, look first for a deadly cause.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosis
On the exam
A woman faints on sitting up. She has low pressure and a past bleeding ulcer. Expect one best answer.
Pick where and when she is assessed.
Common mistakes
Booking blood tests for tomorrow, or a stool test for hidden blood. A patient this low, with possible bleeding or sepsis, needs emergency care today.
Approach
- Think of a heart attack, a leaking aortic aneurysm, sepsis and a bleed in the gut.
- Ask about black stools, vomiting blood, anti-inflammatories, blood thinners, fever, and pain in the chest, back or belly.
- Low pressure with any of these goes to emergency today. Do not work it up from home.
- A stool test for hidden blood is for screening people without symptoms. A negative result does not rule out a bleed.
- In a patient who uses a catheter, the urine dipstick is often abnormal anyway. It does not prove the urine is the source of sepsis.
| Cause | Clues | First step |
|---|---|---|
| Heart attack | Chest pain, sweating, short of breath. Can be silent in older adults and diabetes. | ECG now |
| Leaking aortic aneurysm | Older smoker, often a man. Back, belly or flank pain. | Emergency, now |
| Sepsis | Fever or low temperature, fast breathing, confusion | Emergency: cultures, fluids, antibiotics |
| Gut bleed | Black stools, vomiting blood, an anti-inflammatory or blood thinner | Emergency: hemoglobin, blood type and screen |
Key feature 6 of 8
When it changes
When long-standing dizziness starts to behave differently, look again for a dangerous cause.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosis
On the exam
Years of stable dizziness, now spells of a new kind. Expect one best answer for the next step.
Pick what to do about the change.
Common mistakes
Blaming the old diagnosis: past positional vertigo, a known migraine, a spinal injury. A new pattern needs its own history and exam.
Approach
- Ask what changed: the type, how often, how long, what sets it off, and any new symptoms.
- Repeat the history, the lying and standing pressures, and the neuro exam as if the problem were new.
- Ask about new drugs, new illness, falls and injuries since the last visit.
- An old drug can still cause a new drop if something else changed. Ask about fluid loss, kidney problems, weight loss and new drugs.
- New neuro signs, a faint, chest pain or a fall with head injury need urgent assessment.
Key feature 7 of 8
Drug review
Check every drug, including ones bought without a prescription, for a cause you can stop.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Health Canada, Choosing Wisely Canada
On the exam
Near-faints began days after a new prostate pill. Expect one best answer for the most likely cause.
Pick the drug that fits the timing.
Common mistakes
Blaming a beta-blocker he has taken for years, or a sleep aid bought after the spells began. The culprit started before the first spell.
Approach
- List every drug: prescription, bought without a prescription, herbal, alcohol and cannabis. Ask for the bottles or the pharmacy list.
- Line up each start date and dose change against the first spell.
- Alpha-blockers such as tamsulosin can lower pressure, and rarely cause fainting. Warn about this when you start one.
- At the first dizziness or weakness on an alpha-blocker, the patient should sit or lie down until it passes.
- Do not combine two alpha-blockers. Take care adding an erection drug such as sildenafil: both lower pressure.
- In older adults, do not pick benzodiazepines or other sleeping pills first. They can more than double the risk of falls and hip fracture.
- Check all drugs at every move between care settings, and stop the ones no longer needed.
| Drug group | Examples | How it makes people dizzy |
|---|---|---|
| Blood pressure drugs and alpha-blockers | Tamsulosin, doxazosin, diuretics, nitrates | Low pressure on standing |
| Sleeping pills and sedatives | Benzodiazepines, zopiclone, sedating antihistamines | Drowsy, unsteady, falls |
| Anticholinergics | Diphenhydramine, oxybutynin | Confusion, blurred vision, unsteadiness |
| Rate-slowing drugs | Beta-blockers, digoxin | Slow pulse; beta-blockers also blunt the pulse rise on standing |
Key feature 8 of 8
Who to scan
Test further when brain signs, an injury or a blood thinner point to a dangerous cause.
CFPC skill SelectivityPhase InvestigationSources Choosing Wisely Canada
On the exam
An 80-year-old on apixaban fainted and hit his head. He looks well. Expect one best answer for the next step.
Pick where and when to image.
Common mistakes
Watching him at home, booking an outpatient scan, or stopping the blood thinner. None of these finds a bleed today. A normal exam does not make him low risk.
Approach
- New brain signs or a new severe headache need brain imaging today.
- After a faint, consider a CT head if there are high-risk features. These include injury above the collarbones, headache, an ongoing neuro deficit, age over 65, a blood thinner or known cancer.
- After a minor head injury, use a validated rule such as the Canadian CT Head Rule to decide on CT.
- Without those features, a simple faint with a normal neuro exam usually needs no CT, MRI, carotid ultrasound or EEG.
- Do not screen with special balance or hearing tests. The story and the office exam make the diagnosis.
- Stopping a blood thinner neither finds nor rules out a bleed. It also leaves him unprotected from the clot the drug was for.
Flashcards
Answer it first, then check.
KF 2He says he feels “dizzy”. What do you ask first?
What it feels like, without the word dizzy: spinning, about to faint, or blacked out.
KF 3She cannot stand, even with help. How do you check her pressure on rising?
Lying down, then sitting up with legs down. Forcing her to stand risks a fall.
KF 4When does the HINTS bedside exam apply?
Only in constant spinning with nystagmus. In spells or near-faints, its result means nothing.
KF 4Brief spinning when he rolls over in bed. What comes before an Epley manoeuvre?
A positive Dix-Hallpike test. If it is negative, think of other causes before repositioning. Source: Choosing Wisely Canada
KF 5Dizzy, low pressure, a past bleeding ulcer, taking naproxen. Where is she assessed?
In emergency, today. A gut bleed is likely, and tests booked for tomorrow are unsafe.
KF 7Near-faints began days after tamsulosin started. What do you tell him?
It is a likely cause. At the first dizziness, sit or lie down until it passes. Source: Health Canada
KF 8After a faint, which features make you consider a CT head?
High-risk features such as injury above the collarbones, headache, an ongoing neuro deficit, age over 65, a blood thinner or known cancer. Source: Choosing Wisely Canada
KF 1A simple faint and a normal neuro exam. Do you order a carotid ultrasound?
No. Carotid imaging rarely finds the cause of a simple faint with a normal neuro exam. Source: Choosing Wisely Canada
FAQ
Which Canadian guideline covers dizziness?
None covers it as a whole. Choosing Wisely Canada says when not to scan after a faint or a head injury. Health Canada drug labels list dizziness and fainting as side effects.
Is the HINTS exam on the test, and who can use it?
Know what it is for. It helps tell a stroke from vestibular neuritis in constant spinning with nystagmus. It needs a trained examiner, and it does not apply to spells or near-faints.
Do children get dizzy for the same reasons?
Most faints in children and teens are harmless reflex faints. A faint during exercise, a faint while lying down, or a family history of sudden death points to the heart.
Does a normal ECG mean the dizziness is harmless?
No. An ECG catches some rhythm problems, but spells can come and go. Low pressure, a bleed, a stroke or a drug can all cause dizziness with a normal ECG.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada