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**Eli:** Hey Miles, I had this patient last week who came in saying "Doctor, the room won't stop spinning!" and honestly, my first thought was - okay, classic vertigo, probably BPPV, let's do the Dix-Hallpike. But here's what caught me off guard - she also mentioned some hearing loss and tinnitus. Suddenly I'm thinking, wait, this might not be as straightforward as I thought.
**Miles:** Oh, that's such a perfect example of why vertigo can be tricky! You know, it's fascinating how that combination of symptoms immediately changes your differential, right? Because BPPV typically doesn't cause hearing problems, but when you add hearing loss and tinnitus to vertigo, you're looking at something like Ménière's disease or even vestibular neuritis.
**Eli:** Exactly! And what really struck me is how the patient's description of "spinning" could mean so many different things. I mean, some patients say spinning when they mean lightheaded, others mean true rotational vertigo.
**Miles:** Right, and that's why the systematic approach becomes so crucial. The TiTrATE method - timing, triggers, and targeted examination - can really help us sort through these cases methodically. So let's dive into how we can build that diagnostic framework that works reliably in family practice.