History Taking · Intermediate · Neurology

Brief Spinning Sensation

Practise this PLAB 2 history taking station on Benign Paroxysmal Positional Vertigo. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Reena Jain, a 62-year-old woman, has come to see you with episodes of severe dizziness that happen when she moves her head in certain directions. She is frightened and wants to know what is wrong. Please take a focused history, perform examination including Dix-Hallpike manoeuvre, and discuss management and treatment options.

Background notes: PMH: Hypertension (managed on medication)

What this station tests

  • Distinguishing BPPV from other vertigo causes through duration and triggers: brief (seconds), positional, reproducible, with symptom-free intervals
  • Excluding Meniere's disease (no hearing loss, tinnitus, or aural fullness) and vestibular neuritis (no sustained vertigo lasting hours)
  • Excluding central causes: no headache, diplopia, dysarthria, or limb weakness suggesting posterior circulation pathology
  • Performing and explaining the Dix-Hallpike manoeuvre as a diagnostic test and the Epley manoeuvre as treatment
  • Teaching Brandt-Daroff exercises for home management and recurrence prevention

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Vertigo triggered by specific head movements is BPPV until proven otherwise. The candidate must distinguish positional vertigo (BPPV) from sustained vertigo (vestibular neuritis, Meniere's, central causes) through the duration, triggers, and associated features. Mrs Jain is 62, presenting with 2 weeks of severe spinning episodes triggered by head movements. She is frightened it might be a stroke. Open with: 'Mrs Jain, tell me exactly what happens when you feel dizzy. What brings it on and how long does it last?' Duration and triggers are the diagnostic keys.

Core approach

Establish the BPPV pattern. Episodes are triggered by specific head movements: rolling over in bed, tilting head backwards, bending down, looking up, washing hair. The vertigo (true rotational spinning, not lightheadedness) starts almost immediately after the provoking movement, lasts 30 seconds to a minute, then stops completely. She feels nauseous during episodes but has not vomited. Between episodes she feels completely normal. This pattern, brief, positional, reproducible, with symptom-free intervals, is diagnostic of BPPV.

Distinguish from other causes of vertigo through negative features. No hearing loss, no tinnitus, no aural fullness (excludes Meniere's disease). No sustained vertigo lasting hours (excludes vestibular neuritis). No headache, no diplopia, no dysarthria, no limb weakness (excludes central causes including posterior circulation stroke). Vertigo is brief and positional, not sustained and spontaneous.

Ask about risk factors: age over 50 (yes), head trauma (none), previous ear problems (none), osteoporosis (ask, associated with BPPV). PMH: hypertension (managed).

Assess functional impact. She is avoiding head movements, not bending down, not looking up, not turning in bed. She is afraid to drive (worried about turning her head at junctions). She has stopped yoga and gardening. The impact on daily function is significant despite the benign nature of the condition.

Closing and safety netting

Provide confident reassurance and explain the mechanism: 'Mrs Jain, this is not a stroke. What you have is called benign paroxysmal positional vertigo, or BPPV. Small crystals in your inner ear have become dislodged and are moving in the balance canals, sending false signals to your brain when you move your head. It is the commonest cause of vertigo and it is very treatable.'

Perform the Dix-Hallpike manoeuvre to confirm the diagnosis (explain what you are about to do and that it will briefly provoke the vertigo). If positive (vertigo plus nystagmus after latency), proceed to the Epley manoeuvre as treatment. Explain: 'The treatment involves moving your head through a series of positions to guide the crystals back to where they belong. It works in about 80% of people after one or two sessions.'

Teach Brandt-Daroff exercises for home use. Explain that BPPV can recur (approximately 50% within 5 years) and that the exercises can help if it does. Address her driving concern: she can drive once vertigo is controlled and she feels safe turning her head. Safety net: 'If you develop hearing loss, constant vertigo that does not stop, headache, or any weakness or speech difficulty, come back immediately as these would suggest a different cause.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for benign paroxysmal positional vertigo. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: BPPV pattern confirmed: brief, positional, reproducible. Meniere's excluded (no hearing loss, tinnitus, aural fullness). Vestibular neuritis excluded (no sustained vertigo). Central causes excluded (no headache, diplopia, dysarthria, weakness). Trigger and duration documented precisely.

Costs marks: Not establishing episode duration. Not excluding hearing symptoms. Not excluding central features. Diagnosing BPPV without excluding alternatives.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Dix-Hallpike planned or performed. Epley manoeuvre as treatment. Brandt-Daroff exercises taught for home use. Recurrence information provided. Appropriate safety netting distinguishing peripheral from central causes. Driving advice.

Costs marks: Not mentioning Dix-Hallpike. No treatment offered. No home exercises. Prescribing medication (betahistine, prochlorperazine) as primary treatment instead of repositioning. No safety netting for central causes.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Firm reassurance that this is not a stroke. Explaining the crystal mechanism in lay terms. Warning that Dix-Hallpike will briefly provoke vertigo. Addressing her fear of driving. Empowering her with home exercises for self-management.

Costs marks: Hedging about stroke risk. Not explaining the mechanism. Performing Dix-Hallpike without warning. Not addressing the impact on her daily activities. Using 'benign' without explaining what that means.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not establishing the brief, positional nature of the vertigo. BPPV episodes last seconds to a minute. Meniere's lasts hours. Vestibular neuritis lasts days. Candidates who do not ask 'how long does each episode last?' cannot distinguish between these diagnoses.
  2. Not performing or mentioning the Dix-Hallpike manoeuvre. This is both the diagnostic test and the gateway to the Epley manoeuvre treatment. Candidates who diagnose BPPV clinically but do not mention Dix-Hallpike miss the confirmatory test and the treatment opportunity.
  3. Not excluding central causes. A 62-year-old with new-onset vertigo needs posterior circulation stroke excluded. Candidates who do not ask about headache, diplopia, dysarthria, and limb weakness cannot safely diagnose a peripheral cause.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a benign paroxysmal positional vertigo history in PLAB 2?

Vertigo triggered by specific head movements is BPPV until proven otherwise. The candidate must distinguish positional vertigo (BPPV) from sustained vertigo (vestibular neuritis, Meniere's, central causes) through the duration, triggers, and associated features. Mrs Jain is 62, presenting with 2 weeks of severe spinning episodes triggered by head movements.

Where are marks won and lost in this benign paroxysmal positional vertigo station?

Examiners reward: BPPV pattern confirmed: brief, positional, reproducible. Meniere's excluded (no hearing loss, tinnitus, aural fullness). Vestibular neuritis excluded (no sustained vertigo). Candidates are penalised for: Not establishing episode duration. Not excluding hearing symptoms. Not excluding central features. Diagnosing BPPV without excluding alternatives.

Where do candidates most often go wrong in this station?

Not establishing the brief, positional nature of the vertigo. BPPV episodes last seconds to a minute.

Can I do well in this station without real-world experience of benign paroxysmal positional vertigo?

This station rewards process over personal experience. The skill being assessed: Excluding Meniere's disease (no hearing loss, tinnitus, or aural fullness) and vestibular neuritis (no sustained vertigo lasting hours). Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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