CASE INFORMATION

Case ID: CCE-SUM-03
Case Name: Sarah Thompson
Age: 52
Gender: Female
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 the patient to gather relevant information about symptoms and concerns 1.2 Provides clear and empathetic explanations regarding the diagnosis and management plan
2. Clinical Information Gathering and Interpretation	2.1 Takes a detailed history, including onset, duration, and triggers of dizziness 2.2 Differentiates between peripheral and central causes of vertigo/dizziness
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Meniere’s disease, or central causes 3.2 Identifies red flags requiring urgent referral (e.g., stroke, brainstem pathology)
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions 4.2 Ensures appropriate follow-up and safety measures to prevent falls
5. Preventive and Population Health	5.1 Provides education on vestibular rehabilitation, fall prevention, and triggers for dizziness
6. Professionalism	6.1 Demonstrates patient-centred care and acknowledges the impact of dizziness on quality of life
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and referral pathways when needed
8. Procedural Skills	8.1 Performs the Dix-Hallpike manoeuvre and Epley manoeuvre if indicated
9. Managing Uncertainty	9.1 Recognises when symptoms require further investigation or specialist input (e.g., MRI for central causes)
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies cases requiring urgent intervention, such as posterior circulation stroke or vestibular migraine

CASE FEATURES

Middle-aged woman presenting with recurrent episodes of dizziness lasting seconds to minutes.
Triggered by head movements, suggesting a peripheral cause such as BPPV.
Mild nausea but no hearing loss, tinnitus, or neurological symptoms.
Concerned about whether this is a sign of something serious, such as a stroke.
Needs assessment to differentiate between peripheral and central causes.
Requires education on BPPV, safety precautions, and vestibular exercises.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Sarah Thompson, a 52-year-old retail worker, presents with recurrent dizziness for the past two weeks. The dizziness comes in short episodes lasting less than a minute and is triggered by turning her head, rolling over in bed, or looking up. She describes the sensation as spinning rather than light-headedness.

She has mild nausea during episodes but no hearing loss, tinnitus, ear pain, or neurological symptoms. She has no chest pain, palpitations, syncope, or weakness.

Sarah is worried that this could be something serious, like a stroke or a brain tumour, and wants to know what tests she needs.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 52
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Occasionally takes paracetamol for headaches

Past History

No history of migraines, cardiovascular disease, or previous vertigo episodes
No known inner ear disorders

Social History

Works full-time in retail, often on her feet

Family History

No family history of stroke, neurological disorders, or balance problems

Smoking

Non-smoker

Alcohol

Drinks socially (1-2 glasses of wine per week)

Vaccination and Preventative Activities

Up to date with routine vaccinations

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I’ve been getting these dizzy spells for the last couple of weeks. It happens when I turn my head or roll over in bed. It’s really unsettling, and I’m worried it could be something serious, like a stroke.”

General Information

You are Sarah Thompson, a 52-year-old retail worker. Over the past two weeks, you’ve been experiencing recurrent episodes of dizziness. The dizziness comes on suddenly, usually when you turn your head, roll over in bed, or look up at a shelf. Each episode lasts less than a minute, but it feels like the room is spinning around you.

Specific Information

(Reveal only when asked)

The dizziness is not constant—it comes and goes, but when it happens, it makes you feel off balance and uneasy. You sometimes feel a little nauseous, but you haven’t vomited. You haven’t fainted or blacked out, and you don’t feel like you’re going to lose consciousness.

You’re starting to feel worried because the dizziness is interfering with your daily life. You work in retail, where you are on your feet all day, and you sometimes have to bend down or reach up to grab items. You’re afraid that you might fall or drop something at work.

You’re also anxious about what could be causing it. You’ve read about strokes and brain tumours, and you’re scared this could be something serious. You’re wondering if you need a brain scan or specialist referral.

Dizziness Symptoms

The dizziness comes in brief episodes, lasting less than a minute.
It only happens when you move your head in certain positions (rolling over in bed, looking up, bending down).
The sensation is spinning, not light-headedness or a feeling of being pulled to one side.
You feel mildly nauseous but haven’t vomited.

What You DON’T Have

No headaches, weakness, numbness, or vision problems.
No slurred speech, difficulty swallowing, or trouble walking.
No chest pain, palpitations, or fainting spells.
No ear pain, ringing in the ears (tinnitus), or hearing loss.

Medical and Family History

You are generally healthy.
You don’t have a history of migraines, heart disease, diabetes, or previous stroke.
No family history of neurological disorders, balance problems, or strokes.

Social History

You work full-time in retail, standing for most of the day.
You live alone but have family nearby.
No recent travel, head injuries, or infections.
No known anxiety disorder, but feeling stressed due to the dizziness.

Concerns and Expectations

You are worried that this could be a stroke or something serious.
You want to know if you need a brain scan or specialist referral.
You feel frustrated because the dizziness is affecting your work and daily life.
You want to know if there is a treatment that will stop this from happening.

Emotional Cues & Body Language

You appear mildly anxious when discussing the possibility of a stroke.
You demonstrate dizziness by turning your head slowly when describing symptoms.
You seem relieved if the doctor explains the diagnosis clearly.
If the doctor does not provide a structured plan, you ask more about tests and treatment.

Questions for the Candidate (Ask Naturally During the Consultation)

“Do I need a brain scan to rule out something serious?”
“Could this be a stroke?”
“Will this go away on its own, or do I need treatment?”
“Is there anything I can do to prevent it from happening?”
“Could this mean I have an ear problem?”
“Will I always have this, or can it be cured?”
“What happens if I ignore it? Will it get worse?”

Response to Advice Given by the Candidate

If the candidate explains BPPV clearly, you feel reassured but still ask about the possibility of a stroke.
If they recommend the Dix-Hallpike manoeuvre, you ask if it is safe and if it will make you feel worse.
If they suggest vestibular exercises, you ask how long they take to work.
If they mention medications like prochlorperazine, you ask if you need to take them daily.
If the doctor dismisses your concerns without explanation, you push for further tests or a referral.

Final Thought

If the candidate explains the likely diagnosis well, reassures you, and provides a structured management plan, you feel relieved and confident in following their advice. If they are vague, dismissive, or fail to address your concerns about serious illness, you remain anxious and push for tests or a specialist referral.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptom onset, duration, and associated features.

The competent candidate should:

Clarify the characteristics of the dizziness:
- Onset: Two weeks ago.
- Duration: Episodes lasting less than a minute.
- Triggers: Head movements (turning head, rolling over in bed, looking up).
- Type: Spinning sensation (vertigo), not light-headedness or feeling faint.
Assess for associated symptoms:
- Mild nausea but no vomiting.
- No hearing loss, tinnitus, or ear pain (reducing likelihood of Meniere’s disease).
- No headaches, neurological symptoms, or focal weakness (reducing likelihood of stroke or brain tumour).
Identify risk factors and red flags:
- No history of cardiovascular disease, migraines, or neurological conditions.
- No chest pain, palpitations, or syncope.
- No recent infections, head trauma, or new medications.
Explore patient concerns and expectations:
- Fear of stroke or brain tumour.
- Impact on daily life (difficulty at work, fear of falling).
- Desire for a clear diagnosis and treatment plan.

Task 2: Identify key clinical features and assess whether this is a peripheral or central cause of dizziness.

The competent candidate should:

Recognise features suggestive of benign paroxysmal positional vertigo (BPPV):
- Short episodes of vertigo (<1 minute).
- Triggered by head movements.
- Absence of neurological symptoms.
Differentiate from other causes:
- Meniere’s disease: Recurrent vertigo lasting hours, associated with tinnitus and hearing loss.
- Vestibular neuritis: Prolonged vertigo (days), often post-viral.
- Stroke or central cause: Persistent vertigo, focal neurological deficits, ataxia.
Decide if further investigations are needed:
- Dix-Hallpike manoeuvre for posterior canal BPPV.
- Neurological examination to rule out central causes.
- MRI referral if red flags present (e.g., progressive symptoms, neurological findings).

Task 3: Explain the likely diagnosis, management options, and need for follow-up.

The competent candidate should:

Explain the diagnosis clearly:
- Likely BPPV, a common and benign inner ear condition.
- Caused by loose crystals in the inner ear stimulating the balance system.
Provide reassurance:
- Not a stroke or brain tumour.
- Symptoms are unpleasant but not dangerous.
Discuss treatment options:
- Epley manoeuvre to reposition crystals in the inner ear.
- Vestibular rehabilitation exercises to speed recovery.
- Avoidance of sudden head movements during acute episodes.
Plan follow-up:
- Review in 2-4 weeks if symptoms persist.
- Consider referral to ENT if persistent or atypical symptoms.

Task 4: Develop a safe, evidence-based management plan, including symptom control, safety precautions, and referral if necessary.

The competent candidate should:

Symptom relief strategies:
- Epley manoeuvre for BPPV.
- Vestibular exercises (Brandt-Daroff exercises).
- Short-term medication (prochlorperazine) if nausea is significant.
Safety precautions:
- Avoid sudden movements, especially when getting out of bed.
- Minimise risk of falls at home/work.
When to seek urgent care:
- Worsening dizziness, severe headache, difficulty speaking, or weakness (stroke signs).
Follow-up and referral:
- Review in 2-4 weeks.
- Refer to ENT if symptoms persist or are atypical.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history, assessing symptom duration, triggers, and associated features.
Differentiates between peripheral (BPPV) and central (stroke, tumour) causes of vertigo.
Explains BPPV clearly, reassuring the patient.
Develops a structured management plan, including Epley manoeuvre, safety advice, and follow-up.
Refers for imaging or specialist review if red flags are present.

PITFALLS

Failing to assess for red flag symptoms, missing a possible central cause.
Not performing or recommending the Dix-Hallpike manoeuvre, delaying diagnosis.
Overprescribing vestibular suppressants (prochlorperazine), which can prolong recovery.
Not explaining the benign nature of BPPV, leading to unnecessary anxiety.
Lack of a structured follow-up plan, missing persistent or worsening symptoms.

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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history, including symptom onset, severity, and associated features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between peripheral and central causes of vertigo.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including Epley manoeuvre and vestibular exercises.

5. Preventive and Population Health

5.1 Provides education on vestibular rehabilitation and fall prevention.

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges the impact of dizziness on quality of life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and referral pathways when needed.

8. Procedural Skills

8.1 Performs the Dix-Hallpike manoeuvre and Epley manoeuvre if indicated.

9. Managing Uncertainty

9.1 Recognises when symptoms require further investigation or specialist input.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring urgent intervention, such as posterior circulation stroke or vestibular migraine.

Competency at Fellowship Level

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