ENT Station 2

 

Station 2

I’m spinning around… get out of my way!

 

Candidate Instructions

Setting:

You are a junior doctor working in GP/family medicine. The patient below presents with dizziness.


Name: Dorothy Chambers


Tasks:

1. Take a history from the patient.

2. Give your preferred diagnosis to the examiner.

3. Please answer the examiners question.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: Benign paroxysmal positional vertigo (BPPV)
You are Dorothy Chambers, a 77 year old female.
In this scenario we are asking you to role play a patient attending your GP after you developed vertigo.

Appearance and Behaviour

Nil significant, act dizzy if you move your head around too much (for example when demonstraing what makes symptoms worse).

Opening statement

“Oh doctor, you’ve got to help me! I’m really struggling to cope with this dizziness… I just cannot shake off. I really need something doing about it… I’m struggling to go about my day, I live alone and I can’t go on like this”

Information to Give Freely

“It's been going on for a number of days now and it just doesn’t seem to be getting better!”

Presenting Complaint

Onset - sudden onset 7 days ago. You were in bed when it started (candidate needs to specifically ask what you were doing when it came on to get the information).
Character - when asked to describe your dizziness - you feel that the room around you is spinning. You don’t feel light-headed.
Associated symptoms -
  • Infection - no discharge, no erythema, no pain, no throat / cough or cold symptoms
  • Inner ear symptoms - there is nausea during dizziness, no tinnitus or hearing loss, no fullness in the ear
  • Head and neck lesions - no swallowing issues, no neck lumps, no nose bleeds
  • NO recent head trauma
    • Timing - dizziness is intermittent and episodes last a few minutes (candidate needs to specifically ask whether the dizziness is intermittent or constant to be given this information). You feel completely normal between episodes. You have 3-6 episodes on average a day.
    Exacerbating/relieving factors - turning your head or rolling over in bed bring on an episode.
    Severity - it’s severely impacting you and you are not leaving the house as a result, you are scared about falling in public.

    Past Medical History

    Previous similar episodes - None
    Other medical conditions - diabetes
    Previous surgeries - left hip replacement

    Drug History

    Prescribed - Ramipril, Atorvastatin, Metformin (no recent changes)
    Over the counter - Nil
    Allergies - None

    Family History

    Father - had a stroke at 82

    Sister - had a stroke at 71

    Social History

    Smoking - ex-smoker with 10 pack years (quit 10 years ago)
    Alcohol - Nil
    Job - retired receptionist
    ADLs - fully independent and lives in a bungalow, has been struggling since vetigo started
    Travel - you have not driven in the past 3 years but do have a license, no recent travel
    Hobbies - NO scuba diving or swimming

    Systems Review

    ENT - as above
    Infective - Nil
    Headache / vision - Nil
    Neurology - Nil peripheral weakness or numbness, nil headaches
    Voice / Swallow - Nil
    Chest / Abdo / Resp / Urinary - Nil other symptoms

    Ideas / Concerns / Expectation

    Ideas - “I am not sure what this could be… but I’m worried about a stroke… I mean I have a strong family history”
    Concerns - “I’m concerned I may have had a stroke and will be like this for the rest of my life?”
    Expectations - “I just want to know why I am feeling this way, it’s not normal”

    Discussion / Questions

    After the history is complete the doctor will be asked questions by the examiner.

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     
  • Infective - NO ear pain, NO erythema, NO discharge
  • Infective - NO history of respiratory tract infections
  • Inner ear symptoms - nausea present, NO aural fullness
  • Hearing symptoms - NO hearing loss, NO tinnitus
  • Head and neck - NO neck lumps, NO swallowing difficulty, NO voice change

    • Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     
  • Lives alone
  • Fully independent until this week
  • No carers
  • Lives in a Bungalow
  • Retired receptionist
  • NO diving
  • NO open water swimming
  • NO recent flights
  • NO hobbies which exposure to loud sounds e.g. drumming
  • NO head trauma

    • Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Instruction

     

    Please direct the candidate to give their preferred diagnosis and proceed to ask the following questions.

    Diagnosis & Interpretation

     

    Examiner instruction:

    Question 1: Which bedside examination would help confirm this diagnosis?

    Examiner instruction:

    Question 2: Which bedside manoeuvre would help treat this diagnosis?

    Examiner instruction:

    Question 3: How could you distinguish between BPPV and a stroke in an emergency department?

  • There is a lack of other neurological symptoms such as weakness, numbness, or speech deficit in BPPV
  • The Dix Hallpike test in BPPV would show fatiguability of nystagmus beats, nystagmus does not fatigue in stroke
  • Stroke may also have hearing loss, BPPV would never have hearing loss.
  • The direction of nystagmus can indication BPPV (fixed horizontal movement with a torsional element) or stroke (direction changing on lateral gaze e.g. it beats right on right gaze, but left on left gaze)
  • Candidate identifies an MRI or CT head may be suitable if there is ongoing concern

    • Submit for Scoring

    Tags - ENT | Dizziness | BPPV | Benign Paroxysmal Positional Vertigo

    Station Written by: Dr Faaizah Chishty

    Peer Reviewed by: Dr _______

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