History Taking · Intermediate · Neurology

Dizziness on Standing

Practise this PLAB 2 history taking station on Postural Hypotension. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Margaret Wilson, a 74-year-old woman, has come to see you with dizziness that occurs when she stands up. She is concerned about falling. Please take a focused history to assess the cause and discuss management.

Background notes: PMH: Hypertension (managed on antihypertensives), Hypothyroidism (on levothyroxine), previous UTI

What this station tests

  • Distinguishing postural hypotension from vertigo (BPPV), cardiac dizziness (arrhythmia), and central causes (stroke): the timing (on standing) and character (lightheadedness, not spinning) are key
  • Identifying medication as the cause through temporal association: onset of symptoms corresponding with a recent antihypertensive dose increase
  • Balancing blood pressure control against fall risk in an elderly patient: accepting a slightly higher BP to prevent falls may be the safer option
  • Assessing falls risk comprehensively: near-misses, activity restriction, home environment, and the psychosocial impact of fear of falling
  • Practical postural advice: rising slowly, sitting on the edge of the bed, increasing fluids, compression stockings

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

Dizziness on standing in an elderly patient is postural hypotension until proven otherwise, and the most common cause is medication. The candidate must take a detailed drug history, identify the culprit, and balance blood pressure control against fall risk. Mrs Wilson is 74, presenting with 4 to 5 weeks of dizziness when standing, worse in the mornings. She nearly fell in the kitchen. Open with: 'Mrs Wilson, tell me about the dizziness. When does it happen and what does it feel like?' Distinguish postural dizziness from vertigo, cardiac dizziness, and central causes.

Core approach

Characterise the dizziness. It happens specifically when she stands up from lying or sitting, within the first minute, lasts 30 seconds to 2 minutes, and resolves when she sits down. It is lightheadedness and visual blurring, not true rotational vertigo (not BPPV). Worst in early morning after lying all night. No syncope, but several near-misses. No palpitations, no chest pain, no focal neurology. This is the classic pattern of orthostatic hypotension.

The drug history is the diagnostic key. She has hypertension and is on antihypertensives. Ask specifically: what medications, what doses, and has anything changed recently? The critical finding: her lisinopril was recently increased (or a new agent added). The onset of dizziness 4 to 5 weeks ago corresponds with the medication change. This temporal association is the likely cause.

Assess for other contributing factors. Dehydration (is she drinking enough? Elderly patients often under-hydrate). Hypothyroidism (she is on levothyroxine, check whether adequately replaced). Anaemia (check FBC). Autonomic neuropathy (does she have diabetes? Parkinson's?). Review all medications, not just antihypertensives: any sedatives, tricyclics, or alpha-blockers?

Assess falls risk. She is a retired nurse and knows hip fractures (she has seen many). She is terrified of falling and losing independence. She is restricting her activities (not going out, not going to the shops). Her daughter checks on her regularly but she is increasingly dependent.

Closing and safety netting

The management is medication adjustment balanced against blood pressure control. 'Mrs Wilson, I think the most likely cause of your dizziness is your blood pressure medication, particularly the recent increase in lisinopril. The medication is lowering your blood pressure too much when you stand up.'

Plan: lying and standing BP measurements today (confirm the postural drop). Review antihypertensive doses: reduce or stop the recently changed medication. Check bloods (FBC for anaemia, U&E for dehydration, TFTs for thyroid). The target is a blood pressure that controls hypertension adequately without causing postural symptoms. This may mean accepting a slightly higher BP to prevent falls.

Practical advice: rise slowly from lying (sit on the edge of the bed first), increase fluid intake, support stockings if tolerated, avoid hot environments. Safety assessment: grab rails, non-slip mats, adequate lighting. Address her fear of falling: 'Reducing the medication should improve the dizziness within a few days.' Safety net: 'If you actually faint, or the dizziness is not improving after the medication change, come back.' Follow-up BP check in 1 to 2 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for postural hypotension. 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: Postural pattern established (on standing, first minute, resolves sitting). Detailed drug history with recent changes. Contributing factors assessed (hydration, thyroid, anaemia). Falls risk assessment. Activity restriction documented.

Costs marks: Not establishing postural timing. Not checking medication history. Not assessing falls risk. Not checking for contributing causes.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Lying and standing BP planned. Medication dose reduction/adjustment. Bloods (FBC, U&E, TFTs). Practical postural advice. Home safety assessment. Balance between BP control and fall prevention. Follow-up BP in 1 to 2 weeks.

Costs marks: Not measuring postural BP. Not adjusting medication. No practical advice. No home safety discussion. No follow-up plan.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Acknowledging her fear of falling and losing independence. Using her nursing background (she understands hip fractures). Providing reassurance that medication adjustment should help quickly. Practical advice she can implement immediately.

Costs marks: Dismissing her fear of falling. Not using her nursing knowledge constructively. Being vague about improvement timeline. Not acknowledging her restricted activities.

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 taking a detailed drug history with recent changes. The onset of postural symptoms 4 to 5 weeks ago coinciding with a medication change is the diagnosis. Candidates who attribute the dizziness to 'getting older' without reviewing medications miss the most treatable cause.
  2. Not measuring lying and standing BP. Postural hypotension is defined as a systolic drop >20 mmHg or diastolic >10 mmHg within 3 minutes of standing. Candidates who do not plan to confirm this objectively cannot make the diagnosis.
  3. Not assessing falls risk. A 74-year-old with postural dizziness and near-misses is at high risk of hip fracture. Candidates who treat the blood pressure without assessing home safety, grab rails, and lighting miss the practical intervention that prevents injury.

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

How do I approach the consultation in this postural hypotension station?

Dizziness on standing in an elderly patient is postural hypotension until proven otherwise, and the most common cause is medication. The candidate must take a detailed drug history, identify the culprit, and balance blood pressure control against fall risk. Mrs Wilson is 74, presenting with 4 to 5 weeks of dizziness when standing, worse in the mornings.

What does a strong performance look like to the examiner in this station?

Strong performances show: Postural pattern established (on standing, first minute, resolves sitting). Detailed drug history with recent changes. Contributing factors assessed (hydration, thyroid, anaemia). Weak performances: Not establishing postural timing. Not checking medication history. Not assessing falls risk. Not checking for contributing causes.

What is the biggest pitfall in this postural hypotension station?

Not taking a detailed drug history with recent changes. The onset of postural symptoms 4 to 5 weeks ago coinciding with a medication change is the diagnosis. Candidates who attribute the dizziness to 'getting older' without reviewing medications miss the most treatable cause.

How should I prepare for postural hypotension if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Identifying medication as the cause through temporal association: onset of symptoms corresponding with a recent antihypertensive dose increase. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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