The spinning bed — posterior canal BPPV, right ear

Posterior canal BPPV is diagnosed on the provoked beat, not the referral letter: latency, torsional up-beat, a duration under a minute and fatigability are the four features the AAN practice parameter and the AAO-HNSF guideline both name, and neither sends this presentation for imaging or bloods. Treatment follows the mechanism — the Epley maneuver moves the canaliths out of the canal in the clinic, with a re-test before she leaves — and the same guideline recommends against routine vestibular suppressants, which sedate without touching the debris. What you do with it: confirm the right ear on the Dix-Hallpike, reposition today, re-test, teach her the position log for the nights, and keep the atypical-feature list close, because the mimic that matters is the positional beat without latency or fatigue.

• A down-beating or purely horizontal persistent beat, no latency, no fatigability, or any other central sign — atypical positional nystagmus earns imaging
• New hearing symptoms, headache or diplopia between visits — the diagnosis is reopened, not exercised through

• Four hours of vertigo — triage before treatmentTier 3
• Vertigo with a headache — vestibular migraineTier 2

This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.