Cases/Ear, Nose and Throat

Sudden-onset Dizziness — Free SCA Practice Case

Middle-aged woman with sudden-onset dizziness

Station Timer

12:00

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

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Sarah Jenkins

Age

54 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I can't get out of bed. The room is spinning violently every time I move my head. I think I'm having a stroke."

Medical Records

●PMH: Migraine (rarely, last attack 2 years ago), Anxiety.
●Medications: Sertraline 50mg OD. Sumatriptan 50mg PRN.
●Allergies: NKDA.

Recent Notes

●2 Days Ago: Saw Practice Nurse for routine smear. Normal.

Patient Script

For the friend playing the patient role

Character Overview: You are Sarah. You are terrified. You woke up this morning, turned over to turn off your alarm, and the world "flipped upside down." You feel nauseous and unsafe. You are lying very still in bed during the video call because you are scared to move. You live alone and work as an office manager at a small solicitors' firm. You are someone who likes to feel in control, and right now you feel completely helpless.

Opening Sentence: "Doctor, please help. I woke up this morning, turned my head, and the whole room just spun violently. It was like being on a rollercoaster. I threw up twice. I haven't moved from this pillow for 4 hours because I'm scared it will happen again."

History if Asked (Data Gathering Phase)

●
The Vertigo (Classic BPPV):
- ●Duration: "It only lasts about 30 seconds, maybe a minute. But it feels like forever."
- ●Trigger: "It happens if I roll over in bed, or if I look up to the ceiling. If I stay perfectly still staring straight ahead, I'm okay."
- ●Nature: "Rotational. The room spins round and round."
●
Associated Symptoms (Red Flag Screen):
- ●Hearing: "My hearing is fine. No buzzing or ringing." (Rules out Labyrinthitis/Meniere's).
- ●Neurology: "No double vision. No weakness in my arms or legs. My speech is normal." (Rules out Stroke).
- ●Ear Pain: "No pain."
●
The "Examination" Expectation:
- ●"I looked online and it said you need to move my head to test for crystals. Can you do that now? I need to know what this is."

ICE — Ideas, Concerns, Expectations

(Actor guidance: do not volunteer any of this unprompted. These responses surface only if the candidate directly explores the patient's perspective.)

●Ideas: "I don't know what's causing it — I just keep thinking stroke. My mum had a stroke at 60 and it started with dizziness. I know I'm probably being dramatic but it's all I can think about lying here."
●Concerns: "I'm terrified it's something serious. And honestly, even if it's not, I live on my own — what if it happens when I'm on the stairs or driving? I could really hurt myself. I can't just lie here forever."
●Expectations: "I just want to know what this is and that it's not dangerous. And I need something that will make it stop — I've got to be back at work tomorrow, I can't just not turn up."

If Asked — Medical History and Medications

(Actor guidance: respond naturally only if the candidate asks about past medical history or current medications.)

●Sertraline / Anxiety: "Yes, I've been on sertraline for about two years. I started it after a bad patch — I was having panic attacks and couldn't sleep. It's been really helpful actually, I've felt much more level. But this morning, honestly, I nearly had a full-blown panic attack when the spinning started. I thought I was dying."
●Migraine: "I used to get migraines years ago — bad ones with the flashing lights and everything. But I haven't had one in at least two years. This doesn't feel like a migraine at all — there's no headache, no aura, nothing like that. It's purely the spinning."
●Sumatriptan: "I've still got some in the cupboard but I haven't needed to take it in ages."
●Recent smear: "Yes, I was in two days ago to see the nurse for a routine smear. Everything was fine — nothing to do with this."

Social History and Lifestyle Impact

(Actor guidance: this context can be shared naturally in conversation, especially if the candidate asks about work, home situation, or how the condition is affecting daily life.)

●Occupation / daily life: Sarah is an office manager at a small solicitors' firm. She is the only admin staff member and feels responsible for keeping everything running. She lives alone in a two-storey house.
●Lifestyle impact: "I'm supposed to be in work today — I'm the only one who does the admin and they'll be completely stuck without me. I've already had to ring and say I can't come in and I feel awful about it. I can't even get up to make a cup of tea without the room going. I tried to walk to the bathroom earlier and I had to hold onto the wall the whole way. I live on my own so there's nobody here to help me. If this carries on I genuinely don't know what I'm going to do."

If Asked — Associated Symptoms

(Actor guidance: respond only if the candidate asks directly about these symptoms. Keep answers brief and natural.)

●If asked about headache: "No, no headache at all. It's just the spinning."
●If asked about nausea or vomiting: "Yes, I threw up twice this morning. I still feel queasy now but I haven't been sick again since I stopped moving."
●If asked about recent ear infection or cold: "No, I haven't had a cold or anything. My ears have been fine."
●If asked about falls or unsteadiness when walking: "I haven't actually fallen, but when I tried to walk to the bathroom I was all over the place — I had to hold onto the wall. I wouldn't trust myself on the stairs."
●If asked about numbness or tingling: "No, nothing like that."
●If asked about difficulty swallowing or facial drooping: "No, nothing like that at all."
●If asked about neck pain or recent neck injury: "No, my neck is fine. No injuries."
●If asked about recent head trauma: "No, nothing like that."
●If asked about fever: "No, I don't feel hot or cold. Just sick."
●If asked about blood pressure or feeling faint: "I don't know my blood pressure. I don't feel faint exactly — it's not that woozy lightheaded feeling, it's the room physically spinning."
●If asked about previous episodes of vertigo: "Never. This is the first time anything like this has happened."
●If asked about alcohol intake: "I'm not a big drinker — maybe a glass of wine at the weekend. I didn't drink last night."
●If asked about stress: "Work has been quite busy lately, but nothing I'd say is out of the ordinary. The sertraline keeps me on a fairly even keel."

Responses to Management (The Negotiation Phase)

●
If the Doctor asks you to perform a self-test (Dix-Hallpike):
- ●Reaction: Fearful. "You want me to do it? I'm scared I'll vomit again. Can't I just come in and you do it?" (Tests the doctor's ability to risk assess remote vs. face-to-face).
●
If the Doctor prescribes Betahistine (Serc):
- ●Reaction: "Will that stop the spinning immediately? I have to drive to work tomorrow."
●
If the Doctor diagnoses 'Vertigo' (BPPV):
- ●Reaction: "Is that serious? Is it a brain tumour? My aunt had dizziness and she had a tumour."
●
If the Doctor mentions 'Epley Manoeuvre':
- ●Reaction: "What's that? Is it surgery? Will it hurt?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Clinical Learning Points

Diagnosing BPPV: The Classic Clinical Picture

●BPPV (Benign Paroxysmal Positional Vertigo) is diagnosed clinically. The three essential features are: rotational vertigo, triggered by specific head movements (rolling over in bed, looking up, bending forwards), lasting less than 60 seconds, with complete symptom-free intervals when the head is still.
●The key word is paroxysmal — attacks are brief and recurrent, not continuous. A history of continuous vertigo lasting hours or days should prompt you to consider a different diagnosis.
●It is the most common cause of vertigo in primary care and is caused by displacement of otoconia (calcium carbonate crystals) from the utricle into the posterior semicircular canal, where they create aberrant fluid movement with head position changes.

Distinguishing BPPV from Other Causes of Vertigo

●Vestibular neuritis / labyrinthitis: Vertigo is continuous, lasting days rather than seconds. Often follows a viral illness. Labyrinthitis is distinguished by concurrent hearing loss, which vestibular neuritis does not cause.
●Menière's disease: Episodes last 20 minutes to several hours and are associated with fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Ask specifically about these three features.
●Migraine-associated vertigo: Can mimic BPPV but is usually associated with headache or other migrainous features (photophobia, phonophobia, aura). Relevant here given Sarah's migraine history — the absence of headache or aura in this episode argues strongly against it.
●Central / posterior circulation stroke: The critical differential in any patient presenting with acute vertigo. See Section 3 below.

Red Flag Screening — Stroke and Central Causes

●
A 54-year-old presenting with acute new-onset vertigo and a family history of stroke at 60 requires systematic red flag screening. The following features suggest a central cause and require urgent assessment:
- ●Focal neurological deficit: limb weakness, facial droop, numbness or tingling
- ●Diplopia, dysarthria, or dysphagia
- ●New severe headache (especially occipital) or neck pain
- ●Vertical or direction-changing nystagmus
- ●Gait ataxia disproportionate to the degree of vertigo
- ●Continuous vertigo with no positional triggers
●Absence of all neurological symptoms in a patient with classic positional, brief, rotational vertigo strongly supports a peripheral cause. The clinical picture here is reassuringly benign — but the screening must be done explicitly and documented.
●HINTS criteria (Head Impulse, Nystagmus, Test of Skew) can differentiate central from peripheral vertigo in patients where uncertainty remains, but requires face-to-face examination.

The Dix-Hallpike Test

●Dix-Hallpike is the gold standard diagnostic test for posterior canal BPPV. A positive test reproduces the patient's vertigo and elicits geotropic rotatory nystagmus (beating towards the affected, lowermost ear) with a short latency of 5–20 seconds, lasting less than 60 seconds.
●In a video consultation: A standard Dix-Hallpike cannot be safely performed remotely — the patient is unsupported and at risk of falling or vomiting without assistance. Options are: (1) treat presumptively based on a classic history; (2) invite for a face-to-face appointment for formal testing and an Epley manoeuvre; (3) guide a careful remote positional test only if the patient has adequate support and a safe environment.
●A classic, unambiguous BPPV history (as in this case) is sufficient to justify presumptive treatment without waiting for formal testing.

Primary Treatment: The Epley Manoeuvre

●The Epley manoeuvre is the evidence-based curative treatment for posterior canal BPPV. It repositions the displaced otoconia from the semicircular canal back into the utricle, where they can no longer cause aberrant fluid displacement.
●Cure rate is approximately 80% after a single session. It should be offered as first-line treatment and explained clearly as a repositioning procedure, not surgery.
●Important: The manoeuvre commonly provokes a brief, intense recurrence of vertigo during the procedure itself. Warn the patient explicitly — this is expected, temporary, and means the treatment is working. Failure to warn risks loss of trust and may cause the patient to stop mid-procedure.
●Home Epley: Safe and effective. Send a reliable visual resource (NHS or Ménière's Society video). Advise the patient to have a bowl nearby and, if possible, someone present during the first attempt. Verbal instructions alone are insufficient for a complex positional manoeuvre.
●Recurrence: BPPV recurs in approximately 50% of patients within 5 years. The Epley can be repeated for further episodes.

Vestibular Rehabilitation: Brandt-Daroff Exercises

●Brandt-Daroff exercises are a vestibular rehabilitation technique that can be used alongside the Epley manoeuvre. They promote central vestibular compensation and reduce the risk of recurrence.
●Advise the patient to begin these once the acute phase has settled. They involve a series of side-lying movements performed 3 times daily for 2 weeks.
●Also advise practical measures during the acute phase: sit up slowly, avoid sudden head movements, sleep with the head slightly elevated on the affected side, and avoid looking upwards.

Medication — What to Use, What to Avoid

●
Vestibular sedatives (antiemetics) have a role in acute symptom management only. Use a short course — maximum 7 days — to manage nausea and vomiting sufficiently to allow the patient to tolerate the Epley manoeuvre.
- ●Prochlorperazine (buccal or oral) or cyclizine are appropriate first-line options.
- ●Do not continue beyond 3 days: prolonged use suppresses central vestibular compensation — the process by which the brain adapts to the inner ear deficit — and delays recovery.
●Betahistine is not recommended for BPPV. It has no evidence base for this condition. Betahistine is indicated for Ménière's disease. Prescribing it for BPPV is a common and significant error.
●Prescribing safety — prochlorperazine and sertraline: Both drugs lower the seizure threshold; combined use increases the risk of additive sedation and, rarely, extrapyramidal effects. If prescribing prochlorperazine to a patient on sertraline, counsel explicitly about increased drowsiness. Cyclizine does not share this interaction profile and is the safer choice in this patient.

DVLA Guidance

●Patients with BPPV must not drive if they are liable to sudden attacks of disabling dizziness. The DVLA requires that driving ceases until the condition has resolved and sudden attacks are no longer occurring.
●For Group 1 licence holders (standard car/motorcycle): the patient may return to driving when symptom-free. There is no requirement to notify the DVLA for BPPV if symptoms resolve fully.
●Advise clearly and specifically — "be careful" is not adequate. Sarah must not drive until she is entirely free of acute attacks.

Safety Netting and Follow-Up

●When to seek urgent help (A&E or 999): If any of the following develop — new limb weakness, facial droop, slurred speech, double vision, difficulty swallowing, severe new headache, or loss of consciousness. These are red flags for posterior circulation stroke.
●When to contact the surgery: If vertigo becomes continuous (lasting more than 24 hours without stopping), if new hearing loss or tinnitus develops, or if symptoms have not improved within 4 weeks of starting treatment.
●Follow-up: Arrange a face-to-face review within a few days if the home Epley is unsuccessful or the patient is too symptomatic to attempt it. A phone review at 1–2 weeks to confirm symptom resolution is good practice.
●Recurrence: Reassure the patient that recurrence is common but that the Epley can simply be repeated. Early recognition of future episodes will allow prompt self-management.

Common Candidate Mistakes in This Case

●Prescribing betahistine for BPPV. This is one of the most common prescribing errors in SCA dizziness cases. Betahistine is for Ménière's disease, not BPPV. - Prescribing vestibular sedatives as the primary or sole treatment. Medication manages symptoms; the Epley manoeuvre treats the cause. A candidate who prescribes prochlorperazine and arranges follow-up without mentioning the Epley has fundamentally missed the management.
●Failing to warn about DVLA restrictions. The patient's specific concern about driving to work tomorrow is a prompt — a candidate who does not address this gives incomplete and potentially unsafe advice.
●Giving generic safety-netting ("come back if you're worried"). The purpose of safety-netting in this case is to distinguish new neurological deterioration (stroke) from expected symptom fluctuation. Generic advice fails this test.
●Failing to address the patient's stroke and tumour fears directly. Blanket reassurance ("it's not serious") without clinical reasoning leaves the patient's specific fears unresolved. Explain why the picture is not consistent with stroke — no focal neurology, no continuous vertigo, classic positional triggers.

Mapped to the RCGP curriculum topic: Ear, Nose and Throat.

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