Start with an open question

Begin by allowing Alex to describe the dizziness and his concerns.

“Can you tell me more about the dizziness and what has been worrying you?”

Then summarise his agenda:

“So the main problem is a spinning sensation when you move your head, and you’re worried it could be something serious. Is that right?”

Time-efficient data gathering

Clarify what Alex has already tried, including:

• Over-the-counter medication.
• Rest.
• Avoiding particular movements.
• Changes to food or drink.
• Any self-management strategies.

Then focus on the key diagnostic distinction: what Alex means by “dizzy”.

Clarify whether he means:

• Spinning sensation or vertigo.
• Light-headedness.
• Feeling faint.
• Unsteadiness.
• A sense of imbalance.
• Difficulty walking.

High-yield questions

Nature and timing of dizziness

Ask:

• “When did this start?”
• “Was the onset sudden or gradual?”
• “How long does each episode last?”
• “Is it constant or does it come and go?”
• “Is it triggered by turning your head or changing position?”
• “Is it getting worse?”
• “What makes it better or worse?”

Neurological symptoms

Ask about:

• Numbness or weakness.
• Speech disturbance.
• Facial drooping.
• Difficulty walking.
• Loss of coordination.
• Visual disturbance.
• Severe or sudden headache.

Ear and hearing symptoms

Ask about:

• Hearing loss.
• Tinnitus.
• Ear pain.
• Ear discharge.
• New hearing-related symptoms.

Cardiac or faintness symptoms

Ask about:

• Palpitations.
• Chest pain.
• Presyncope.
• Fainting.
• Feeling light-headed on standing.

Other relevant history

Clarify:

• Previous migraine.
• Recent migraine symptoms.
• Current medication, including amlodipine.
• Blood-pressure problems.
• Recent infections.
• Previous episodes of vertigo.
• Alcohol or substance use where relevant.

Functional, psychosocial or contextual assessment

Explore how dizziness affects Alex’s day-to-day life.

Ask:

“Is this stopping you from showing houses or making you nervous about driving?”

“How has it affected your confidence at work or at home?”

Explore:

• Whether he has stopped driving.
• Whether he feels unsafe driving.
• Whether he has had to cancel work.
• Whether he can walk safely.
• Whether he avoids certain movements.
• Whether anxiety is making symptoms harder to manage.

Explore ideas, concerns and expectations

Alex may be worried about serious brain disease. Explore this directly.

“You mentioned being worried about something like a stroke or tumour. Can you tell me more about that?”

Clarify whether his main goal is:

• Reassurance.
• Symptom relief.
• A diagnosis.
• Advice about work.
• Advice about driving.
• Assessment for serious causes.

Recognise and respond to cues

If Alex says:

“I’m just worried it’s something serious in my brain.”

Respond with acknowledgement before explanation:

“I can understand why that would worry you. Let’s go through the symptoms that would make us concerned about that, and then I’ll explain what seems most likely from what you’ve told me.”

If he appears frustrated by uncertainty:

“Not having a clear answer must be frustrating. We’re going to work together to get to the bottom of this.”

Do not dismiss his concerns simply because the likely cause may be benign.

Useful consultation phrases

“Many people notice a spinning feeling when moving or turning their head suddenly. Has this been your experience?”

“I can’t give a firm diagnosis over this video consultation because I need to examine you, but we can go through the most likely causes and arrange a face-to-face assessment.”

“The most common cause of a spinning feeling triggered by movement is a problem in the inner ear’s balance system.”

“There are no signs you’ve shared that suggest a serious cause, but I still want to examine you properly.”

“If you feel dizzy or unsteady, or if medication makes you drowsy, you should not drive.”

Consultation flow and signposting

1. Establish Alex’s story and main worry.
2. Clarify whether dizziness means spinning, light-headedness or unsteadiness.
3. Ask about timing, triggers and progression.
4. Screen for neurological, hearing, visual and cardiac symptoms.
5. Review migraine history, medication and blood pressure context.
6. Explore impact on work, driving and confidence.
7. Explain likely causes and limits of remote assessment.
8. Arrange face-to-face assessment.
9. Discuss symptom relief and activity advice.
10. Safety-net clearly.

Example signposting:

“Thanks, that helps me rule out some more serious causes. Does it also happen when you stand up, or mainly when you turn your head?”

Summarising and checking understanding

Summarise before management:

“From what you’ve described, the dizziness is mainly triggered by movement, without the neurological warning symptoms we’ve discussed. The likely causes are generally related to the balance system, but I’d like to examine you face to face.”

Check:

• What Alex understands about the likely causes.
• Whether he understands why examination is needed.
• Whether he knows how to keep himself safe.
• Whether he has further concerns about stroke or brain disease.

Data gathering self-check

Before moving to management, the trainee should know:

• Whether Alex’s dizziness is vertigo, light-headedness, faintness or unsteadiness.
• Onset, duration, triggers and progression.
• Whether there are neurological, hearing, visual or cardiac symptoms.
• Whether symptoms affect walking safety.
• Whether symptoms affect driving or work.
• Relevant migraine history.
• Current medication, including amlodipine.
• Blood pressure context.
• What Alex has tried already.
• What he is most worried about.

Assessment domain mapping

Data gathering

• Nature of dizziness.
• Timing, triggers and progression.
• Neurological, auditory, visual and cardiac symptoms.
• Migraine, medication and blood pressure history.
• Impact on work, driving and function.

Clinical management

• Explaining uncertainty in remote assessment.
• Arranging face-to-face review.
• Considering symptom relief.
• Driving and movement safety advice.
• Safety-netting for serious symptoms.

Relating to others

• Acknowledging fear of serious disease.
• Using Alex’s own language.
• Avoiding false reassurance.
• Shared planning around work and driving.

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Prioritised differential diagnosis or clinical reasoning

Use Alex’s presentation to construct a prioritised differential:

1. Benign vestibular dysfunction, such as viral labyrinthitis or vestibular neuritis — most likely if there is vertigo triggered by movement.
2. Vestibular migraine, given the migraine background, although there have been no recent attacks.
3. Orthostatic hypotension or medication side effect, including the possibility of an effect from amlodipine, although this is uncommon.
4. Anxiety-related dizziness, given work stress, although this does not appear to be the dominant explanation.
5. Cardiac causes, less likely in the absence of palpitations or presyncopal symptoms.
6. Central causes, such as stroke, tumour or multiple sclerosis — very unlikely given the slow time course and absence of neurological red flags, but not dismissed without assessment.

Clinical reasoning script

“The pattern you describe — a spinning feeling triggered by head movement — most often comes from the balance system in the inner ear. Migraine or blood pressure can sometimes contribute. Serious brain causes seem less likely from what you’ve told me, but I still need to examine you face to face to be safe.”

Red flags and risk assessment

Arrange urgent assessment if Alex develops:

• New weakness or numbness.
• Difficulty speaking.
• New visual symptoms.
• Facial drooping.
• Loss of coordination.
• Difficulty walking.
• Severe headache.
• New hearing loss.
• Sudden progression.
• Collapse or fainting.
• Chest pain.
• Inability to walk safely.
• Severe vomiting or deterioration.

Decision points

Key decisions include:

• Is this vertigo, light-headedness, faintness or unsteadiness?
• Are there neurological, auditory, visual or cardiac red flags?
• Is face-to-face assessment needed?
• Does Alex need symptom relief?
• Is it safe for Alex to drive?
• Could amlodipine or blood pressure be contributing?
• Is symptom monitoring useful?
• What follow-up is needed if symptoms persist or worsen?

Management priority

The management priority is to manage symptoms safely while arranging face-to-face assessment and ensuring Alex knows when to seek urgent help.

Management options

1. Face-to-face review

Arrange an appointment for physical examination and further assessment.

Explain that remote assessment can identify likely causes and red flags, but may not establish the diagnosis with certainty.

Face-to-face assessment may include:

• Ear examination.
• Neurological examination.
• Gait and balance assessment.
• Blood-pressure assessment, including consideration of postural readings.
• Cardiovascular assessment.
• Further examination based on symptoms.

2. Symptom relief

Consider symptom relief such as prochlorperazine where clinically appropriate.

Discuss:

• Its intended role.
• Possible drowsiness.
• Effects on driving and operating machinery.
• Need to review if symptoms persist or worsen.

3. Positioning and activity advice

Advise Alex to:

• Stand up slowly.
• Avoid sudden head movements.
• Change position carefully.
• Use support if unsteady.
• Avoid walking in unsafe situations.
• Sit or lie down if symptoms become severe.

4. Driving safety

Discuss driving safety explicitly.

Alex may need to avoid driving if:

• He is dizzy or unsteady.
• Medication causes drowsiness.
• He cannot safely control the vehicle.
• Symptoms occur unpredictably.

Advise him to seek further advice if symptoms affect his ability to drive safely.

5. Reassurance and education

Explain that serious causes appear less likely based on the information currently available, while being clear that examination is still required.

Discuss:

• The likely role of the inner ear.
• The relationship between movement and vertigo.
• The possibility of migraine or blood pressure contributing.
• Why imaging may not be necessary unless new concerning features appear.

6. Symptom monitoring

Encourage Alex to keep a symptom diary.

Record:

• When dizziness occurs.
• Type of dizziness.
• Position or movement triggers.
• Duration.
• Food or dietary changes.
• Sleep.
• Stress.
• Headache or migraine symptoms.
• Hearing symptoms.
• Medication timing.
• Impact on work or driving.

This may help identify patterns, particularly in chronic vertigo or vestibular migraine.

7. Review blood-pressure treatment

Review hypertension management if:

• Symptoms worsen when standing.
• Alex feels faint.
• Blood pressure is low.
• There is a possible medication contribution.

Do not stop or change medication without appropriate clinical assessment.

Personalised plan

Adapt the plan to Alex’s work, driving and symptom severity.

A suitable personalised plan might include:

• Face-to-face examination.
• Short-term symptom relief if appropriate.
• Advice about driving and sudden movements.
• A symptom diary.
• Review of blood pressure and medication.
• Clear neurological and hearing-related safety-netting.
• Follow-up if symptoms persist or worsen.

Example phrase:

“Because you’re still able to function and there are no warning signs, we can manage this step by step — symptom relief, a face-to-face check and holding off on scans unless new symptoms appear.”

Shared decision-making

Involve Alex in deciding:

• How quickly he can attend a face-to-face assessment.
• Whether he needs symptom relief.
• How he will manage work and driving.
• What activity modifications are realistic.
• What symptoms would prompt urgent help.
• Whether he would find a symptom diary useful.

Link the plan to his practical concerns:

“Would you like to talk about how you can manage this at work, and what to do if things get worse?”

Safety-netting

Alex should seek urgent help if he develops:

• New weakness or numbness.
• Difficulty speaking.
• New visual symptoms.
• Severe headache.
• New hearing loss.
• Sudden progression.
• Collapse or fainting.
• Chest pain.
• Inability to walk safely.
• Severe vomiting.
• Marked deterioration.

Ensure he understands what to do and who to contact if these occur.

Documentation points

Document:

• How Alex describes the dizziness.
• Onset, duration, triggers and progression.
• Associated neurological, auditory, visual and cardiac symptoms.
• Migraine history.
• Medication history, including amlodipine.
• Impact on work and driving.
• Remote consultation limitations explained.
• Face-to-face assessment arranged.
• Symptom relief discussed or prescribed.
• Driving and activity advice.
• Safety-netting advice.

Common unsafe management plans

Avoid:

• Diagnosing definitively over video without examination.
• Reassuring without asking about neurological symptoms.
• Ignoring Alex’s concern about serious disease.
• Prescribing prochlorperazine without discussing drowsiness and driving.
• Not asking about hearing loss.
• Not considering cardiac symptoms, blood pressure or medication.
• Failing to arrange face-to-face review.
• Giving no safety-netting for sudden deterioration.

Follow-up and coordination with other professionals

Arrange face-to-face review for examination and further assessment.

Follow-up should review:

• Symptom progression.
• Examination findings.
• Response to symptom relief.
• Work and driving safety.
• Blood pressure and medication contribution if relevant.
• Need for further assessment if symptoms persist or red flags develop.

Learner checkpoint

Have I made Alex safer today while acknowledging that the diagnosis needs examination to confirm?

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Relevant guidance areas 

• Vertigo and dizziness.
• Prochlorperazine.
• Communication in simulated consultations.

NICE guidance

• NICE: Vertigo and dizziness.

BNF references

• BNF: Prochlorperazine.

Relevant research or educational references

• Simulated consultations: Sociolinguistic perspective.

Key principles to remember

• Clarify what Alex means by “dizziness”.
• Ask about vertigo, light-headedness and unsteadiness separately.
• Explore hearing, neurological, visual and cardiac symptoms.
• Acknowledge his fear of serious disease.
• Explain likely causes in order of probability.
• Be honest that a video consultation cannot provide a firm diagnosis.
• Arrange face-to-face examination.
• Discuss symptom relief and drowsiness.
• Provide clear driving and positioning advice.
• Consider blood pressure and medication effects.
• Use a symptom diary where helpful.
• Give explicit safety-netting for neurological symptoms, hearing loss and sudden deterioration.

Transferable learning for future cases

In remote consultations for dizziness:

• Do not accept “dizzy” without clarifying what the patient means.
• Reassurance is safest after red-flag screening.
• Acknowledge serious fears before explaining likely benign causes.
• Be explicit about the limits of remote assessment.
• Arrange examination when diagnosis depends on physical findings.
• Give practical advice about driving, work and falls risk.
• Safety-net for neurological, hearing and cardiac symptoms.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Clear differentiation between vertigo, presyncope and unsteadiness.
• Direct exploration of Alex’s fear of stroke or tumour.
• Red-flag screening.
• Recognition that video consultation cannot confirm diagnosis.
• Appropriate face-to-face assessment plan.
• Safe discussion of prochlorperazine and drowsiness.
• Driving and activity advice.
• Specific safety-netting.

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Final learner takeaway

In dizziness, first define the symptom, then screen for red flags, explain uncertainty honestly, and arrange examination when remote assessment is not enough.

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