CASE INFORMATION

Case ID: VERTIGO-2025-10
Case Name: Mark Stevens
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: N17 (Vertigo/Dizziness)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to assess dizziness symptoms 1.3 Explains potential causes of vertigo in clear language 1.5 Uses shared decision-making regarding further investigations and management
2. Clinical Information Gathering and Interpretation	2.1 Conducts a structured history to differentiate peripheral from central causes of vertigo 2.3 Identifies red flags suggestive of serious underlying pathology
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between common causes of vertigo (e.g., BPPV, vestibular neuritis, Meniere’s disease, central causes) 3.5 Recognises when urgent referral or imaging is required
4. Clinical Management and Therapeutic Reasoning	4.2 Provides evidence-based management for benign vertigo conditions 4.5 Discusses pharmacological and non-pharmacological treatment options
5. Preventive and Population Health	5.1 Advises on safety measures to prevent falls and injury due to vertigo 5.3 Educates on lifestyle modifications and triggers for vertigo
6. Professionalism	6.1 Provides reassurance while addressing patient concerns
7. General Practice Systems and Regulatory Requirements	7.1 Documents examination findings, diagnosis, and management plan clearly 7.2 Ensures appropriate referral pathways for concerning symptoms
9. Managing Uncertainty	9.1 Addresses diagnostic uncertainty by considering a stepwise approach to investigation
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when vertigo is a symptom of a serious neurological or cardiovascular condition

CASE FEATURES

Middle-aged male presenting with sudden onset vertigo and nausea for the past three days.
Vertigo is worsened by head movements but no hearing loss or tinnitus.
No neurological deficits, chest pain, or history of stroke or cardiovascular disease.
Concerned about whether it could be serious (e.g., stroke, tumour).
Needs education on benign causes of vertigo and management strategies.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Stevens
Age: 58
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5mg daily for hypertension

Past History

Hypertension (diagnosed 5 years ago, well-controlled)
No previous history of vertigo, stroke, or cardiovascular disease

Social History

Works as a carpenter, concerned about fall risk
Lives with his wife, no recent travel or infections
Non-smoker, occasional alcohol consumption

Family History

No known family history of stroke or neurological disorders

Smoking

Non-smoker

Alcohol

Drinks 2–3 standard drinks per week

Vaccination and Preventative Activities

Up to date with health checks, including cardiovascular risk screening

SCENARIO

Mark Stevens, a 58-year-old carpenter, presents with a three-day history of dizziness and nausea. The dizziness is worsened by turning his head and feels like the room is spinning. He has had no hearing loss, tinnitus, or ear pain.

He has no weakness, slurred speech, double vision, or loss of coordination. His blood pressure is well-controlled, and he has no history of stroke or cardiovascular disease.

Mark is concerned about whether this could be a serious condition, such as a stroke or brain tumour.

On examination, his head impulse test is positive, and Dix-Hallpike manoeuvre reproduces vertigo. There are no cerebellar or neurological deficits.

He seeks advice on what is causing the vertigo, how to manage it, and whether further tests are needed.

EXAMINATION FINDINGS

General Appearance: Well, alert, no distress
Vital Signs:

Temperature: 36.7°C
Heart Rate: 72 bpm
Blood Pressure: 128/78 mmHg
Respiratory Rate: 16 breaths per minute
Oxygen Saturation: 98% on room air

Neurological Examination:

No focal neurological deficits (normal motor, sensory, reflexes)
Normal cranial nerve function
No limb ataxia or dysmetria
Negative Romberg’s test

Vestibular Examination:

Positive Dix-Hallpike test (reproduces vertigo, brief nystagmus)
Positive head impulse test
No vertical nystagmus or gaze palsy

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s vertigo?

Prompt: How do you differentiate between peripheral and central causes of vertigo?
Prompt: What red flags would suggest the need for urgent imaging?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: What are the most common causes of vertigo in this patient’s age group?
Prompt: How do you differentiate BPPV from vestibular neuritis or Meniere’s disease?

Q3. How would you manage Mark’s vertigo?

Prompt: What role does the Epley manoeuvre play in treatment?
Prompt: When would medications be indicated, and what options are available?

Q4. How would you counsel Mark on safety and lifestyle modifications?

Prompt: What precautions should he take to minimise fall risk at work and home?
Prompt: How do you address his concerns about a serious cause like a stroke or tumour?

Q5. What follow-up plan would you implement?

Prompt: When should he return for review?
Prompt: When would referral to neurology or ENT be necessary?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s vertigo?

A structured history and focused examination are essential to differentiate peripheral from central causes of vertigo and identify any serious underlying pathology.

1. History

Symptom characterisation:
- Onset: Sudden or gradual?
- Duration: Seconds, minutes, hours, or days?
- Triggers: Head movements, postural changes, or spontaneous?
- Associated symptoms: Nausea, vomiting, hearing loss, tinnitus, visual changes, diplopia.
- Pattern: Episodic vs. continuous.
Red flag symptoms suggesting central cause (e.g., stroke, tumour):
- Severe headache, neurological deficits, limb weakness, diplopia, dysarthria, ataxia.
- New onset in older age (>60 years), history of vascular disease.
Past medical history:
- Hypertension, diabetes, migraine, cardiovascular disease.
- Previous vertigo episodes and response to treatment.
Medication history:
- Recent use of ototoxic drugs, antihypertensives, sedatives.
Impact on daily life and safety risks:
- Falls, ability to work, driving safety.

2. Examination

Vital signs:
- Blood pressure (postural drop), heart rate.
Neurological exam (assess for central causes):
- Cranial nerves: Nystagmus (vertical = central, horizontal = peripheral), facial asymmetry.
- Cerebellar signs: Dysmetria, dysdiadochokinesia, Romberg’s test.
- Limb weakness, hyperreflexia, sensory loss (central pathology).
Vestibular tests (assess for peripheral causes):
- Dix-Hallpike manoeuvre: Positive in BPPV (transient vertigo, latency, fatigability).
- Head impulse test: Positive in vestibular neuritis (corrective saccade).
- Skew deviation test: Suggests brainstem pathology.

A structured approach helps to differentiate between benign and serious causes, guiding management and referral decisions.

SUMMARY OF A COMPETENT ANSWER

Elicits key history to differentiate peripheral vs. central vertigo.
Identifies red flags requiring urgent imaging and referral.
Performs focused neurological and vestibular examination.
Uses Dix-Hallpike and head impulse tests to confirm peripheral vertigo.

PITFALLS

Failing to assess red flag symptoms, potentially missing a stroke or serious pathology.
Not distinguishing between BPPV, vestibular neuritis, and central causes.
Overlooking cardiovascular risk factors in an older patient with dizziness.
Relying on medication alone without considering vestibular rehabilitation exercises.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured history to differentiate peripheral from central causes of vertigo.
2.3 Identifies red flags suggestive of serious underlying pathology.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD