EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Daniel’s vertigo?

• Prompt: How do you differentiate between peripheral and central causes of vertigo?
• Prompt: What red flags would indicate an urgent referral?

Q2. What further history and investigations would be useful in this case?

• Prompt: What features increase suspicion for a central cause?
• Prompt: When would you consider imaging?

Q3. How would you explain the diagnosis and next steps to Daniel?

• Prompt: How do you reassure him regarding stroke concerns?
• Prompt: How do you explain the benign nature of his condition and the treatment approach?

Q4. Outline your management plan for Daniel’s vertigo.

• Prompt: What non-pharmacological treatments are effective?
• Prompt: When would you prescribe medication or refer to a specialist?

Q5. What preventive strategies should Daniel follow to reduce future vertigo episodes?

• Prompt: How can he modify daily activities to avoid triggering symptoms?
• Prompt: What role does vestibular rehabilitation play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Daniel’s vertigo?

A structured approach is required to differentiate peripheral vs central causes of vertigo.

• Peripheral Causes (More Likely in this Case):
  • Benign Paroxysmal Positional Vertigo (BPPV) – Brief episodes (<1 min), triggered by head movement, positive Dix-Hallpike test.
  • Vestibular neuritis – Sudden onset, persistent vertigo lasting days, no hearing loss, positive Head Impulse Test (HIT).
  • Meniere’s disease – Recurrent vertigo episodes lasting hours, hearing loss, tinnitus.
• Central Causes (Must Exclude):
  • Posterior circulation stroke/TIA – Sudden vertigo with diplopia, dysarthria, limb weakness, or ataxia.
  • Brainstem tumour/MS – Gradual onset, progressive, associated with other neurological signs.
  • Vestibular migraine – History of migraines, episodic vertigo, photophobia, phonophobia.
• Other Causes:
  • Orthostatic hypotension – Dizziness on standing, BP drop >20mmHg systolic.
  • Medication-induced vertigo – Amlodipine, ototoxic drugs.

A competent candidate prioritises peripheral causes while ruling out central pathology.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Vertigo characteristics: Duration, triggers, associated symptoms (tinnitus, hearing loss, neurological signs).
  • Red flags: Sudden onset, diplopia, dysphagia, limb weakness, altered consciousness.
  • Medications: Antihypertensives, ototoxic drugs.
• Examinations:
  • Dix-Hallpike test – Confirms BPPV if positive.
  • Head Impulse Test (HIT) – Abnormal in vestibular neuritis, normal in central causes.
  • Cerebellar examination – Dysmetria, dysdiadochokinesia suggest central cause.
• Investigations (if needed):
  • MRI Brain – If stroke suspected (abnormal neuro exam, persistent symptoms).
  • Audiometry – If hearing loss present.

A competent candidate tailors investigations based on clinical suspicion.

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Q3: How would you explain the diagnosis and next steps to Daniel?

1. Acknowledge concerns:
   • “I understand that vertigo can be unsettling, and you’re concerned about stroke.”
2. Explain likely diagnosis:
   • “Your symptoms and the positive Dix-Hallpike test suggest BPPV, a common and treatable cause of vertigo.”
3. Reassure but safety-net:
   • “BPPV is not dangerous and occurs due to tiny crystals in the inner ear moving abnormally.”
   • “You do not have neurological symptoms that suggest a stroke, but if you develop weakness, vision changes, or speech difficulties, seek urgent care.”
4. Discuss treatment:
   • “We can perform a repositioning manoeuvre today, and most people improve within weeks.”

A competent candidate provides clear explanations, reassures, and outlines safety-netting.

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Q4: Outline your management plan for Daniel’s vertigo.

1. Repositioning Manoeuvre:
   • Epley manoeuvre for posterior canal BPPV.
   • Education on home exercises (Brandt-Daroff exercises).
2. Symptomatic Treatment (Short-term only):
   • Prochlorperazine or meclizine for severe symptoms (≤3 days).
   • Avoid long-term vestibular suppressants to prevent delayed recovery.
3. Referral if Atypical Features:
   • ENT referral if refractory or uncertain diagnosis.
   • Neurology referral if concern for central pathology.
4. Follow-Up:
   • Review in 1–2 weeks to assess response.
   • Reassess if persistent or worsening symptoms.

A competent candidate uses evidence-based management, minimises unnecessary medications, and provides appropriate follow-up.

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Q5: What preventive strategies should Daniel follow to reduce future vertigo episodes?

1. Vestibular Rehabilitation Exercises:
   • Encourage Brandt-Daroff exercises for long-term adaptation.
2. Activity Modifications:
   • Advise caution with rapid head movements.
   • Educate on fall prevention strategies.
3. Regular Monitoring of Cardiovascular Risk Factors:
   • BP and lipid control to reduce stroke risk.
   • Smoking cessation, diet, and exercise.
4. Medication Review:
   • Minimise vestibular suppressants to avoid long-term imbalance.
   • Monitor for drug-induced dizziness (e.g., antihypertensives).

A competent candidate ensures a holistic, long-term approach to symptom prevention.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates between peripheral and central vertigo, prioritising BPPV based on positive Dix-Hallpike test.
• Identifies red flag symptoms, ruling out stroke and cerebellar pathology.
• Uses targeted bedside tests, including Dix-Hallpike and Head Impulse Test.
• Clearly communicates the diagnosis, reassuring the patient while addressing concerns.
• Implements an evidence-based management plan, including repositioning manoeuvres and symptomatic treatment.
• Advises on preventive strategies, including vestibular rehabilitation and cardiovascular risk reduction.

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PITFALLS

• Failing to differentiate between peripheral and central causes, leading to missed stroke diagnosis.
• Not performing Dix-Hallpike or Head Impulse Test, missing key diagnostic clues.
• Over-relying on medications, leading to delayed vestibular recovery.
• Not addressing safety-netting, failing to warn about worsening neurological symptoms.
• Neglecting cardiovascular risk reduction, missing an opportunity for stroke prevention.

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REFERENCES

• RACGP – RACGP Guidelines on Stroke Risk Assessment
• GP Exams – Vertiginous syndrome

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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

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

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