Counselling · Intermediate · Psychiatry

Dizzy Spells After Fall

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

Clinical scenario

You are an FY2 doctor in primary care. Khadija Adebayo, a 78-year-old woman, has come to see you following a fall at the surgery reception area three days ago. She has been experiencing intermittent dizziness since the fall and is very anxious about falling again. She lives alone and is concerned about her ability to remain independent. Please take a focused history and discuss management and safety planning with her.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Hypothyroidism, Osteoarthritis (knees, hands), Cataract surgery

What this station tests

  • Multifactorial falls assessment: postural BP, medication review, vision, home hazards, strength and balance
  • Amitriptyline as a falls risk in elderly: highly anticholinergic, causes sedation and postural hypotension
  • Fear of falling as a vicious cycle: avoidance leads to deconditioning, which increases falls risk
  • Strength and balance programme: evidence-based physiotherapy for falls prevention
  • Home hazard assessment: occupational therapy referral for safety modifications

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

A fall in an elderly patient living alone requires comprehensive assessment: injury management, falls investigation, home safety, and addressing the psychological impact (fear of falling). Mrs Adebayo is 78, widowed, fell at home yesterday and is now frightened to move. Open with: 'Mrs Adebayo, I am sorry about the fall. Tell me what happened and how you are managing.'

Core approach

Assess the fall. What was she doing (getting up from chair, reaching for something)? Did she trip, slip, or feel dizzy? Any warning symptoms (palpitations, chest pain, visual changes)? Any loss of consciousness? Check for postural hypotension (medication-related), arrhythmia, or mechanical fall.

Assess for injury. Any pain (hip, wrist, head)? Can she weight-bear? Any head injury? Prolonged lie (how long was she on the floor)?

Medications: review all medications for falls risk. Antihypertensives (postural hypotension), sedatives, anticholinergics, opioids. She is on amlodipine, bendroflumethiazide, and amitriptyline (for neuropathic pain). Amitriptyline is highly anticholinergic and a significant falls risk in elderly patients.

The psychological impact is as important as the physical. She is now afraid to move, restricting activities, and losing confidence. Fear of falling creates a vicious cycle: reduced activity leads to deconditioning, which increases falls risk.

Closing and safety netting

Multifactorial falls assessment. Lying and standing BP (postural hypotension). Medication review (consider stopping amitriptyline, reducing diuretic). Vision check. Home hazard assessment (occupational therapy). Strength and balance exercise programme (physiotherapy referral, evidence-based for falls prevention). Bone health (calcium, vitamin D, DEXA if not done).

Address the fear of falling. 'The fear you are feeling is very common after a fall, but avoiding movement actually increases your risk of falling again. A physiotherapist can help you rebuild your confidence safely.' Consider personal alarm. Safety net: 'If you fall again, feel faint, or develop new pain, contact us.' Follow-up in 2 weeks.

How examiners mark this station

Examiners will assess your ability to explain postural hypotension and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1 (Primary focus)

Scores well: Fall circumstances established. Injury assessed. Medications reviewed (amitriptyline identified). Postural BP planned. Vision checked. Home environment assessed.

Costs marks: Not investigating fall cause. Not reviewing medications. Not checking postural BP.

Domain 2 (Primary focus)

Scores well: Medication adjustment (amitriptyline). Physio referral for strength and balance. OT for home hazards. Bone health. Personal alarm considered.

Costs marks: No medication review. No physio. No home assessment. Not addressing bone health.

Domain 3 (Primary focus)

Scores well: Addressing fear of falling. Explaining the deconditioning cycle. Empowering with physio and safety modifications. Not dismissing her anxiety.

Costs marks: Dismissing fear. Not explaining the cycle. Not empowering.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Not reviewing medications: amitriptyline in an elderly patient is a significant falls risk that may be stoppable
  2. Only treating the injury without investigating the cause: why she fell determines prevention
  3. Not addressing fear of falling: psychological impact drives activity restriction and further deconditioning

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this postural hypotension counselling consultation?

A fall in an elderly patient living alone requires comprehensive assessment: injury management, falls investigation, home safety, and addressing the psychological impact (fear of falling). Mrs Adebayo is 78, widowed, fell at home yesterday and is now frightened to move.

Where are marks won and lost in this postural hypotension station?

Examiners reward: Fall circumstances established. Injury assessed. Medications reviewed (amitriptyline identified). Postural BP planned. Vision checked. Home environment assessed. Candidates are penalised for: Not investigating fall cause. Not reviewing medications. Not checking postural BP.

Where do candidates most often go wrong in this station?

Not reviewing medications: amitriptyline in an elderly patient is a significant falls risk that may be stoppable.

Can I do well in this station without real-world experience of postural hypotension?

Structure beats experience here. Focus on amitriptyline as a falls risk in elderly: highly anticholinergic, causes sedation and postural hypotension. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

Related cases