ℹ️ This is the case information for the doctor.
Name
Alex Turner
Age
47 years old
Address
24 Letchworth Close
Social history
Occupation: Estate Agent,
Living situation: Married, 2 children
Past history
Hypertension (diagnosed age 43, well-controlled)
Migraine (since twenties, infrequent episodes – every 2-3 months, usually with visual aura and bad headache, responsive to Sumatriptan)
No surgeries
Investigation results
Last bloods (routine hypertension review) 10 months ago – all normal.
BP at last check: 128/76.
Medication
Amlodipine 5mg daily
Sumatriptan 50mg as needed for migraines (uses infrequently, last taken 2 months ago)
No allergies
Booking note
Dizziness
ℹ️ This is the information for the person role playing the patient.
Name
Alex Turner
Age
47 years old
Address
24 Letchworth Close
Social history
Occupation: Estate Agent,
Living situation: Married, 2 children
Past history
Hypertension (diagnosed age 43, well-controlled)
Migraine (since twenties, infrequent episodes – every 2-3 months, usually with visual aura and bad headache, responsive to Sumatriptan)
No surgeries
Medication
Amlodipine 5mg daily
Sumatriptan 50mg as needed for migraines (uses infrequently, last taken 2 months ago)
No allergies
“Hi doctor, I’ve just been feeling a bit off balance and dizzy?”
Felt lightheaded, dizzy, and a bit unsteady on and off for about 4 weeks.
Worse when getting up quickly, or moving around (e.g. coming down stairs, turning quickly).
Occasionally feels like the room is spinning very slightly for a few seconds, especially if he turns his head quickly or bends down.
The dizziness sometimes feels like the room is moving or spinning (“I suppose it is a bit like things are moving round, especially fast movements – is that vertigo?”)
No double vision, visual changes (other than usual migraine aura, which he hasn’t had during this time).
No weakness, numbness, or speech difficulties.
No chest pain, palpitations, shortness of breath, feeling faint, or loss of consciousness.
No trauma or hits to head/neck.
No recent foreign travel, tick bites, ear infections, or viral illnesses.
No feelings of low mood or panic attacks; occasionally feels “pretty stressed,” but doesn’t notice dizziness being worse when he’s stressed.
Has felt mildly nauseous but hasn’t vomited or needed time off work.
No hearing loss or buzzing in the ears.
No significant headaches – “just my usual migraine, which I haven’t had for two months.”
Still driving but being more careful.
Not fallen over, but does feel cautious.
Still able to work and look after himself/family.
Not started any new meds; Amlodipine and Sumatriptan only.
No sedating medications or recreational drug use.
No excess caffeine.
Wonders if he has some kinf of infection or perhaps something more serious.
Worried it might be something serious in his brain ("like a tumour or stroke or something going on").
Mildly anxious as it’s been going on for a while with little improvement.
Heard about people his age having strokes, so that’s playing on his mind.
Family has suggested Meniere’s but he’s never had ear problems.
Hopes for answers about what’s causing this.
Thinks he probably needs a scan to rule out something serious, “like a brain scan.”
Wants some advice about what he can do to feel more steady – "It’s just starting to affect my confidence when I’m out and about for work."
Father had hypertension, no neurological problems.
No known family history of stroke, MS, ear disease, or brain tumours.
Mildly anxious but polite, trustful of GP. Not acutely ill, just wants to be taken seriously.
Not obviously distressed, but gestures to head and steadiness if describing symptoms. If asked to clarify dizziness, will describe it as a “bit spinny” if prompted, but not dramatic.
If the doctor is empathic and explains that a firm diagnosis often needs further testing/examination, will be understanding but may check “so you really don’t think I need a scan yet?”
If told it is likely to be inner ear-related and needs a stepwise approach, will ask “Is it safe to keep driving / working?”
If the doctor is dismissive or suggests anxiety alone, may appear uncomfortable or ask more directly “but could it be something serious in my head?”
Will accept an offer for symptom relief (“am I ok to take something like that?”) but wishes to avoid drowsiness.
Will agree to further assessment/examination appointment and is reassured by a clear plan.
If reassured it is not likely a stroke or brain tumour, he will be relieved but may double-check “I just want to be sure we’re not missing something dangerous.”
If physical exam is deferred because it’s a video consult, will understand the limitations but expect a face-to-face soon if not improving.
Not interested in time off work, unless told is unsafe.
Will be grateful for clear safety-netting and written info.
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
Elicits key information using by encouraging Alex to describe the symptoms in his own words before progressing to clarifying details about the dizziness (onset, duration, triggers).
Uses logical follow-up questions to clarify the temporal pattern, associated symptoms, and any factors that impact the dizziness severity.
Data gathering was incomplete, lacking structure and focus.
Fails to establish key details of the dizziness, such as when or how it started, or only asks closed or leading questions.
Does not clarify the quality of the dizziness, frequency, or context in which it occurs.
Makes effective use of existing information and considers the wider context.
Reviews Alex’s medical history (hypertension, migraine) and current medications, considering how these may relate to symptom development.
Explores lifestyle factors (occupation, alcohol intake, stress), linking them to possible causes or exacerbating factors.
Fails to use the information provided or understand the wider context.
Ignores or insufficiently explores Alex’s past history, migraine pattern, or antihypertensive medication as possible contributors.
Misses the opportunity to contextualise symptoms by asking about occupational, psychosocial, or lifestyle factors.
The presence or absence of relevant red flags was established.
Enquires about symptoms suggesting serious pathology: severe headache, sudden unilateral hearing loss, stroke features - weakness, speech changes, ataxia, or collapse.
Cardiac risk factors for stroke are considered - about chest pain, palpitations, smoking, atrial fibrillation).
Fails to assess key information necessary to determine risk.
Omits questions about neurological or systemic red flags, such as focal weakness, severe headache, or acute hearing loss.
Does not ask about symptoms that would prompt urgent referral or imaging.
Information gathered placed the problem in its psychosocial context.
Asks about the effect of symptoms on Alex’s work, driving, family life, and emotional wellbeing.
Explores work–life balance, stress, and any mood or anxiety symptoms, relating these to the dizziness.
The social and psychological impact of the problem was not adequately determined.
Does not enquire about how symptoms affect Alex’s daily living, work confidence, or quality of life.
Neglects psychological and social contributors or consequences of the dizziness.
A working diagnosis was reached using a structured, evidence-based approach.
Progressively narrows down causes by asking about classical features of vertigo, presyncope, and non-specific dizziness.
Considers medication effects, migraine, vestibular causes, and anxiety based on symptom quality and risk factors.
The evidence collected was inadequate to support the conclusions reached.
Jumps to conclusions without clarifying the vertiginous component or adequately excluding other causes.
Lacks a structured approach in synthesising the history to reach a logical diagnosis.
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making.
Assesses likely causes based on Alex’s demographic: vestibular causes and migraine are prioritised; rare or serious causes considered but reasonably deprioritised with no red flag features.
Considers how Alex’s hypertension and medications fit the pattern seen in primary care presentations.
Choice of diagnosis and/or investigations does not reflect disease likelihood.
Makes recommendations or suggests investigations (e.g. urgent scan) not supported by likelihood or risk profile.
Fails to place the most common diagnoses in the context of Alex’s symptoms and background.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Practises holistically, promoting health, and safeguarding:
Links the episode to Alex’s well-controlled hypertension and past migraine history, explaining how these intersect.
Checks the impact on work, driving, and home life, offering advice on safe activity and when to avoid driving.
Fails to safeguard patient welfare:
Ignores impact on Alex’s safety in the community (e.g. driving) or does not account for effects on mental wellbeing.
Manages dizziness in isolation from underlying conditions, potentially overlooking broader health risks.
Manages uncertainty, including that experienced by the patient:
Transparently discusses diagnostic uncertainty and discusses the most likely causes for the symptom picture informed by disease prevalence and epidemiology.
Explains that immediate investigations (e.g. scan) are not needed without red flags, but outlines what would change that assessment.
Struggles with uncertainty, leading to inconsistent decisions:
Either over-investigates (ordering unnecessary scans) or under-explains the rationale for not providing a concrete diagnosis.
Provides vague or contradictory messages about next steps and symptom meaning.
Tailors management options responsively according to circumstances, priorities and preferences:
Involves Alex in decisions, considers his work needs (e.g. advice on driving), and addresses his worry about serious causes.
Adapts educational and symptomatic management advice to Alex’s expressed anxiety, family expectations, and occupational concerns.
Management options fail to adequately consider patient preference and circumstance:
Does not enquire about or respond to Alex’s concerns, priorities, or life context (e.g. just issues generic advice).
Rigidly dictates management without offering options or shared decision making.
Offers management options that are safe and appropriate:
Discusses stepwise approach: offers face-to-face appointment for targeted examination to manage uncertainty and identify likely diagnosis.
Offers symptom relief (e.g. short course of prochlorperazine) while awaiting review.
Fails to provide appropriate and or safe management choices:
Fails to recommend in-person examination, risking misdiagnosis or delayed recognition of serious pathology.
Ignores symptom relief, leaving Alex unsupported, or inappropriately suggests high-level investigations (e.g. head CT) without clinical justification.
Empowers self-care and independence:
Provides advice on minimising symptom triggers (e.g. taking care with sudden head movement, staying hydrated).
Explains warning signs for when to seek immediate help or re-consult, building confidence and autonomy.
Management fails to foster self-care and patient involvement:
Omits advice on symptom management or fails to explain when and how Alex should escalate care.
Makes Alex dependent on the GP without offering practical steps to manage minor symptoms day to day.
Prescribes safely considering local and national guidance:
If prescribing for symptom relief, provides clear instructions, discusses potential side effects (e.g. sedation with prochlorperazine), and checks for contraindications.
Reviews Alex’s current medications and interactions before adding anything new.
Unsafe prescribing ignoring best practice:
Prescribes without checking for potential interactions, or withholds symptomatic relief when appropriate.
Offers drugs contra-indicated for patients with migraine or cardiovascular comorbidity.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Shows ability to communicate in a person-centred way:
Acknowledges Alex’s anxiety about the dizziness and how it affects his work and daily activities.
Validates his concerns about possible serious causes and uncertainty about the diagnosis.
Communication is doctor-centred and lacks empathy:
Focuses only on medical questions and explanations, without recognising Alex’s distress or need for reassurance.
Does not acknowledge the impact of the symptoms or Alex’s fears about brain problems.
Treats patients fairly and with respect:
Listens attentively without making assumptions about the cause (e.g. not attributing symptoms to anxiety or stress without evidence).
Respects Alex’s concerns and need for investigation, discussing these sensitively and non-judgementally.
Decisions fail to prioritise the patient’s rights and interests:
Dismisses Alex’s request for further investigation or makes light of his worries.
Ignores Alex’s perspective regarding work or driving safety.
Explores the patient’s agenda, health beliefs and preferences:
Asks Alex directly what he thinks might be causing his dizziness and his expectations for management.
Recognises Alex’s belief that a scan may be necessary and his worries about strokes or tumours.
Fails to recognise thepatient's agenda and impact of the problem:
Does not ask about Alex’s own explanations for his symptoms or explore his wish for specific investigations.
Offers generic advice without addressing Alex’s stated hopes or fears.
Recognises what matters to the patient and works collaboratively to enhance patient care:
Involves Alex in decisions about the next steps (e.g. timing of examination, medication for symptom relief, discussion about escalation).
Acknowledges the importance of his work and family, adapting care to minimise disruption.
Fails to work with the patient to plan care:
Proposes a management plan without inviting Alex’s perspective or input.
Misses opportunities to reassure or partner with Alex in his care.
Demonstrates flexibility of communication adapting to the patient and scenario:
Adjusts explanation to Alex’slevel of understanding, using plain language about vertigo, balance and stepwise investigation.
Offers clarifications when Alex expresses confusion or concern, adapting explanations as needed.
Consults rigidly, providing generic explanations and management plans:
Uses jargon (“peripheral vestibulopathy,” “BPPV”) or fails to explain technical terms clearly.
Repeats the same explanation despite Alex’s queries or signs of confusion.
Takes ownership of decisions, whilst being aware of personal limitations:
Explains clearly that an in-person assessment is needed for examination, while taking responsibility for organising the next steps.
Acknowledges the limitations of video consulting in diagnosing neurological symptoms and arranges appropriate timely follow up.
Does not take ownership or show awareness of personal limitations:
Promises a diagnosis remotely or declines to arrange a timely review despite ongoing uncertainty or limitations in assessment.
Avoids clarifying own responsibility for follow up and managing Alex’s ongoing concerns.
ℹ️ Insights from the examiner
Open questions help uncover Alex’s story efficiently and allow him to reveal keyfeatures and his agenda.
Clarify what Alex has already tried for relief, and check for OTC medications.
Summarise to ensure you have understood the agenda.
Connect by matching your language to Alex’s knowledge and emotions:
You can do this by using the words that Alex uses to describe his symptoms in your questions and explanations.
“Many people notice a spinning feeling when moving or turning their head suddenly—has this been your experience?”
Use plain English (“spinning,”“balance,” “inner ear”) and avoid jargon (“vestibular neuritis”) unless explained.
Spot and respond to cues early:
Verbal: “I’m just worried it’s something serious in my brain.”
Non-verbal: Hesitancy when discussing issues.
Show you’ve heard them:
“You mentioned being worried about something like a stroke or tumour; can you tell me more about that?”
Acknowledge uncertainty andAlex’s discomfort:
“Not having a clear answer mustbe frustrating—we’re going to work together to get to the bottom of this.”
Involve Alex in creating a shared plan:
“Would it be helpful if we made a plan together for managing the dizziness and ruling out anything serious?”
Set realistic expectations:
“I can’t give a firm diagnosis over this video consultation because I need to examine you, but we could go through the most likely causes now and arrange a face-to-face assessment”
Maintain a logical question flow:
Nature of dizziness (“Is it spinning, lightheaded, or unsteady?”)
Associated symptoms (hearing, headache, vision, sensory)
Medical history (including medication and migraine)
Impact on daily life, driving, and work
Acknowledge answers and move forward:
“Thanks, that helps me rule out some more serious causes. Does it ...”
Use Alex’s presentation to construct a differential:
Benign vestibular dysfunction (e.g., viral labyrinthitis/vestibular neuronitis) – most likely with “vertigo” and movement-triggered.
Vestibular migraine – Migraine background, although no recent attacks.
Orthostatic hypotension/medication side effect – Amlodipine rarely, but worth considering.
Anxiety-related dizziness – work stress, but not a dominant picture.
Cardiac causes – less likely (no palpitations, no presyncopal features).
Central causes (CVA, tumour, MS) – very unlikely, slow time course, no neuro signs/red flags.
Use a patient-centred approach to explain the order of likelihood.
Be personal. Explore and record the effects on Alex’s life/work:
“Is this stopping you from showing houses or making you nervous about driving?” “How’s it been for yourconfidence at work or at home?”
Give clear, brief explanations and share your thoughts:
“You have dizziness and sometimes the room feels like it’s spinning. The most common cause is a problem in the inner ear’s balance system, less commonly migraine or blood pressure can play a role. There are no signs you’ve shared that suggest a serious cause, and I'll be able to tell you more once I've examined your ear”
Menu of management options,supporting NICE guidance and best practice:
Arrange a face-to-face review for examination
Offer symptom relief e.g. prochlorperazine (discuss drowsiness)
Safety-netting: advice on when to seek help, including new neuro symptoms,hearing loss, sudden progression.
Advise on positioning and activity (stand up slowly, avoid sudden turns, driving safety)
Reassure and educate—discuss low likelihood of serious pathology
Monitor symptoms and keep a diary if triggered by activity, dietary changes (helpful for chronicvertigo/migraine)
Review hypertension management if symptoms worsen or blood pressure is low
Offer solutions adapted to Alex’s presentation and agenda:
“Because you’re still able to function and there are no warning signs, we can manage this stepwise—symptomatic relief, a face-to-face check, holding off on scans unless new symptoms appear. Would you like to talk about how you can manage at work, and what to do if things get worse.”
Useful References
Simulated consultations: Sociolinguistic Perspective
