8 Months of Intermittent Double Vision — Free SCA Practice Case
Young woman with 8 months of intermittent double vision
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Ellie Dawson
Age
23 years
Consultation Type
VideoAge
23
Situation
Video Consultation.
Reason for Encounter
"I keep getting episodes of double vision — it's been going on for months and I want to know what's causing it."
Medical Records
- ●PMH: Nil significant.
- ●Medications: None.
- ●Allergies: NKDA.
- ●Recent contact: No significant recent consultations.
Patient Script
For the friend playing the patient role
Character Overview: You are Ellie, a 23-year-old graphic designer. For about eight months you have had episodes of double vision, roughly every three or four days, affecting both eyes, sometimes with your peripheral vision going a bit blurry. Each episode resolves on its own after a while, with no clear pattern or trigger you can identify. You have no headaches. You are worried because it keeps happening and you do not know why, and it is starting to affect your work and your driving. You are articulate and cooperative.
Opening Sentence: "Hi Doctor. For about eight months now I've been getting episodes of double vision — it comes and goes, maybe every few days, and my side vision goes a bit blurry too. It settles on its own each time, but there's no pattern to it and it's really worrying me. I don't get headaches with it."
History if Asked (Data Gathering Phase)
- ●The double vision: "It's double vision — two of things side by side. It affects both eyes. It comes on, lasts a while, then settles by itself. About every three or four days for the last eight months."
- ●The peripheral blur: "Sometimes my side vision goes a bit blurry during an episode too."
- ●Pattern/triggers: "I can't find any pattern — not obviously worse at any time of day, no clear trigger."
- ●Headache: "No headaches with it."
- ●Impact: "It's affecting my design work when it happens, and it frightens me about driving."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.
- ●Ideas: Ellie has no idea what is causing it and has been searching online, which has alarmed her. "I've no idea what it is. Reading online has scared me — I've seen all sorts."
- ●Concerns: She is worried it is something serious with her brain or eyes, and about the effect on her work and driving. "I'm scared it's something serious — my brain or my eyes. And I'm worried about work and whether I can drive."
- ●Expectations: She wants it investigated and to know what is going on. "I want to get to the bottom of it and know what it is."
If Asked — Structured Neurological/Ophthalmic Screen
The patient answers these only when directly asked; on video she can perform some guided assessment.
- ●If asked whether the double vision goes away when one eye is covered: "Yes — if I cover either eye, the double vision goes. It's only double with both eyes open." (Binocular diplopia — points to a neurological/muscular cause.)
- ●If asked about fatigability (worse at the end of the day or with sustained gaze): "Maybe a little worse when I'm tired, but it's hard to say." (Screens for myasthenia.)
- ●If asked about drooping eyelids (ptosis): "I haven't noticed my eyelids drooping."
- ●If asked about other neurological symptoms (limb weakness, numbness, tingling, gait/balance): "No weakness or numbness, no balance problems."
- ●If asked about previous episodes suggestive of MS (painful visual loss/optic neuritis, other transient neurological symptoms): "No painful loss of vision before, and no other odd neurological episodes that I can think of."
- ●If asked about difficulty swallowing, chewing, or slurred speech (bulbar/fatigable): "No swallowing or speech problems."
- ●If asked about headache, visual obscurations, pulsatile tinnitus (raised intracranial pressure): "No headaches, no whooshing in my ears."
- ●If asked about thyroid symptoms / eye protrusion: "No, nothing like that."
- ●If asked about general health, medications, pregnancy, smoking, family history (autoimmune/MS): "I'm well otherwise, no medications, not pregnant, non-smoker; no family history I know of."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains this needs structured assessment and referral: "So you can't tell me exactly what it is today, but you need to examine me properly and refer me? That makes sense." (The tested point is honest handling of diagnostic uncertainty with a structured plan.)
- ●If the Doctor arranges a face-to-face examination: "You need to check my eyes and nervous system in person? Okay." (The tested point is arranging appropriate examination.)
- ●If the Doctor explains the referral to neurology (± ophthalmology): "A neurologist? Is it my brain? Should I be really worried?" (The tested point is explaining the referral and the main considerations honestly and proportionately.)
- ●If the Doctor advises about driving: "Can I still drive? I get double vision at the wheel sometimes." (The tested point is safe, correct driving/DVLA advice for diplopia.)
- ●If the Doctor safety-nets: "What would mean I need to be seen urgently?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Binocular vs Monocular Diplopia
- ●The first discriminator in double vision is binocular vs monocular: binocular diplopia resolves when either eye is covered and points to a neurological or neuromuscular cause (cranial nerve palsy, myasthenia, MS, orbital/extraocular muscle disease); monocular diplopia persists with one eye covered and is usually ocular/refractive.
Episodic Binocular Diplopia in a Young Adult
- ●Important considerations include multiple sclerosis (relapsing–remitting neurological episodes, internuclear ophthalmoplegia, optic neuritis), myasthenia gravis (fatigable diplopia/ptosis, worse at the end of the day), cranial nerve palsies, thyroid eye disease, idiopathic intracranial hypertension (usually with headache), and decompensating phoria.
Structured Assessment
- ●Assess fatigability, ptosis, bulbar symptoms (myasthenia), optic neuritis and other transient neurological episodes (MS), headache/visual obscurations/pulsatile tinnitus (raised ICP), and perform a cranial nerve, ophthalmic, and neurological examination (in person).
Handling Diagnostic Uncertainty and Referral
- ●Where the cause is unclear, the safe approach is a structured assessment and appropriate referral (neurology ± ophthalmology) rather than a guessed diagnosis. Match urgency to features — escalate for any acute neurological deficit.
Driving and the DVLA
- ●Diplopia affects fitness to drive. Advise the patient not to drive while experiencing diplopia and about DVLA notification duties — a key safety and medicolegal responsibility.
Safety-Netting
- ●Safety-net for new persistent neurological symptoms, sudden visual loss, severe headache, or limb weakness/speech disturbance, advising urgent/emergency assessment.
Support Through Uncertainty
- ●Communicate uncertainty honestly but calmly, take the patient's fears seriously, and provide follow-up and support.
Common Candidate Mistakes in This Case
- ●Not distinguishing binocular from monocular diplopia: missing the fundamental first step.
- ●Guessing a diagnosis or falsely reassuring: rather than a structured assessment and referral.
- ●Not screening for MS/myasthenia: missing the key serious considerations.
- ●Omitting driving/DVLA advice: a safety and medicolegal failure.
- ●Managing entirely remotely: not arranging the necessary in-person examination.