THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including the characteristics of the vertigo, associated symptoms, and risk factors.

The competent candidate should:

• Clarify the nature of the dizziness, distinguishing between:
  • Vertigo (room spinning sensation) vs. lightheadedness or imbalance.
  • Onset and duration: sudden vs. gradual, episodic vs. constant.
  • Triggers: movement-related (suggests BPPV) vs. spontaneous (suggests central cause).
• Assess associated symptoms, including:
  • Neurological symptoms: weakness, numbness, speech changes (suggestive of central causes).
  • Auditory symptoms: hearing loss, tinnitus, ear fullness (suggestive of Meniere’s disease or vestibular neuritis).
  • Nausea/vomiting: common in both peripheral and central causes but more severe in peripheral.
• Explore risk factors, including:
  • History of stroke, hypertension, hyperlipidaemia, diabetes, smoking, and atrial fibrillation.
  • Medication history (e.g., antihypertensives, sedatives that may contribute to dizziness).
• Elicit patient concerns and expectations, including:
  • “What are you most worried this could be?”
  • “Have you had any recent infections, head trauma, or new medications?”

Task 2: Formulate a differential diagnosis, distinguishing between peripheral and central causes.

The competent candidate should:

• Differentiate between common causes of vertigo:
  • Peripheral causes (more common, less serious):
    • Benign paroxysmal positional vertigo (BPPV) – short, triggered episodes, no hearing loss.
    • Vestibular neuritis – post-viral, sudden onset, prolonged vertigo, no hearing loss.
    • Meniere’s disease – vertigo lasting minutes to hours, with hearing loss and tinnitus.
  • Central causes (less common, but serious):
    • Posterior circulation stroke/TIA – sudden onset, lasting >24 hours, associated with neurological deficits.
    • Cerebellar tumour or multiple sclerosis – progressive vertigo, ataxia, visual changes.
• Identify red flags that suggest a central cause and require urgent referral:
  • Acute persistent vertigo with neurological signs.
  • Severe headache, neck pain, or recent trauma.
  • Sudden onset vertigo with diplopia, dysarthria, limb weakness, or gait instability.

Task 3: Explain the likely diagnosis to the patient, addressing concerns empathetically.

The competent candidate should:

• Acknowledge the patient’s concerns about stroke:
  • “I understand why you’re worried, especially with your mother’s history of stroke.”
• Explain the likely diagnosis in simple terms:
  • “Your symptoms are consistent with benign paroxysmal positional vertigo (BPPV), which occurs when small calcium crystals in the inner ear move into the wrong position, causing brief spinning sensations when you move your head.”
• Reassure but provide clear guidance:
  • “There are no red flag symptoms suggesting a stroke, but if you develop sudden weakness, speech difficulty, or vision changes, you should seek urgent care.”
• Discuss the natural course and treatment:
  • “BPPV often improves on its own but can be treated with simple repositioning exercises.”

Task 4: Develop a management plan, including symptom relief, safety advice, and referral as needed.

The competent candidate should:

• Short-term management:
  • Perform the Dix-Hallpike manoeuvre to confirm BPPV.
  • Treat with the Epley manoeuvre to reposition otoliths.
  • Prescribe vestibular suppressants (short-term only), such as prochlorperazine or meclizine, if symptoms are severe.
• Safety and falls prevention:
  • “Move slowly when getting up or changing position.”
  • “Avoid driving until symptoms resolve.”
• Referral and follow-up:
  • If symptoms persist despite treatment, refer to an ENT specialist for further evaluation.
  • If central causes are suspected, refer for urgent neuroimaging.
  • “Let’s review in a week to see if the exercises are helping.”

SUMMARY OF A COMPETENT ANSWER

• Takes a structured history, distinguishing peripheral vs. central vertigo.
• Identifies red flag symptoms, ensuring serious causes are not missed.
• Explains the diagnosis clearly, using patient-friendly language.
• Provides a structured management plan, including manoeuvres, medications, and safety advice.
• Discusses when referral or imaging is needed, ensuring patient safety.

PITFALLS

• Failing to consider stroke/TIA in a high-risk patient.
• Not performing or documenting key vertigo tests, such as Dix-Hallpike.
• Over-reliance on vestibular suppressants, which delay recovery.
• Failing to provide safety advice, increasing fall risk.
• Not educating the patient on when to seek urgent care.

REFERENCES

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

MARKING

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

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

Competency Areas Assessed

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the 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 comprehensive history of the vertigo and associated symptoms.
2.2 Identifies risk factors for central vs. peripheral vertigo.
2.3 Determines when further investigation or referral is needed.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises common and serious causes of vertigo.
3.3 Determines when urgent referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan based on suspected diagnosis.
4.3 Provides symptom control options (Epley manoeuvre, medications).
4.5 Refers to neurology or ENT when indicated.

5. Preventive and Population Health

5.2 Discusses falls prevention strategies for elderly patients with vertigo.

7. General Practice Systems and Regulatory Requirements

7.2 Follows appropriate guidelines for stroke and neurological assessments.

Competency at Fellowship Level

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