“The room spins when I turn over” — assess and manage

Candidates: do not open until you have consulted.

How to run this station

• With two people: the role player lies on the couch and is tested and treated; the role player also reads out the eye findings (“you see…”) from the script at the moment the candidate holds the position and looks at her eyes. With three: the examiner reads the eye findings and marks.
• No couch: the candidate stands beside the seated role player, describes and mimes every head position and timing aloud, and the eye findings are read out at each step. Mark the talk-through to the same standard.
• Clock: stated hold times are not waited out; the candidate may say how long they would hold each position, the examiner says “that time has passed” and reads the finding, and the station clock keeps running. Wrong side: if the first test or the manoeuvre is on the left, report no vertigo and “no nystagmus”; if the manoeuvre is begun on the right from a wrong position, say “nothing much happening”. If the right test is positive, the candidate may test the left side and then begin the treatment manoeuvre from the right-sided test position.
• Role-player safety: the role player must have no neck, back or cardiovascular problem. Movements on the role player are done at a moderate speed with the head fully supported; if the couch end cannot be cleared, a pillow under the shoulders gives the extension. The examiner may stop any manoeuvre.

Persona and manner

• Gillian Moss, 63, florist — you run a small shop with your husband Keith and do the wedding and funeral deliveries in the van.
• Brisk, practical, slightly embarrassed to be “dizzy like an old lady”; you do not like being lain flat and will say so.

Opening line — say this verbatim

• “Every time I turn over in bed the whole room spins. It only lasts a few seconds but it’s horrible — and I nearly went over on the shop steps last week.”

How to show the signs

• At rest: normal — walk in steadily, sit normally.
• When you are lain back quickly with the head turned to the right: count silently to five, then say “oh — it’s spinning” and grip the couch; keep your eyes open and looking ahead if the doctor has asked you to; let it ease after about twenty seconds — “it’s going now.” Do not close your eyes unless the doctor forgets to tell you to keep them open.
• When lain back with the head turned to the left: nothing — “no, that’s fine.”
• During the treatment manoeuvre on the right: a brief spin in the first position (as above), then in each later position say “a bit” for a few seconds and then “it’s settling.” When sat up: “ooh — a bit woozy,” then you are fine.
• If the doctor sits you up without a hand under your head: “Careful — my neck.”
• If the doctor goes to lie you back without warning or without asking: “Hang on — what are you doing?”

Volunteer freely if given the space

• Two weeks ago you woke up, turned over to the right and the room spun for about half a minute; you felt sick. It has happened most days since — turning over in bed, lying back at the hairdresser’s, looking up at the top shelf in the shop.
• Between attacks you are fine, just a bit wary of moving your head.

Only if asked

• Each spin lasts well under a minute — “probably twenty seconds, it feels like an hour.” Always set off by moving your head; never out of the blue sitting still.
• No hearing loss, no ringing in the ears, no fullness or pressure in the ear, no ear pain or discharge; no recent cold or ear infection.
• No headache; no double vision; no numbness, weakness, clumsiness or trouble speaking; no trouble walking between attacks. No head injury. No chest pain or palpitations; no blackouts.
• You have never had this before. Nobody in the family has had it. Your sister had a stroke at 70 that “started with dizziness” — only if asked about family history or what you are worried about; otherwise keep it for the ‘anything to add’ line.
• Neck: stiff in the mornings for years; the physiotherapist said “wear and tear”; you can turn your head fully and look up at the ceiling without pain. No rheumatoid arthritis, no neck operation, no whiplash. Back is fine.
• Heart and blood vessels: no history of stroke or mini-stroke; no angina; nobody has told you that you have a narrowed artery in the neck. Blood pressure has always been normal.
• Nearly fell: last week, reaching up for a vase on the top step of the shop ladder, the room went and you grabbed the shelf — Keith caught the vase. You have not fallen.
• Driving: you drive the van most days for deliveries; no spinning while driving so far — but you have avoided looking over your shoulder when reversing.
• Medicines: just the thyroid tablet. No sedatives, no travel-sickness tablets. No allergies.

Impact on daily life — home and work (only if asked)

• You have stopped going up the shop ladder and Keith is doing the high displays; you are sleeping propped on three pillows to avoid turning over.
• You have cancelled your hair appointment because of the backwash basin.
• The wedding season starts in a fortnight and you do all the van deliveries — Keith does not drive the van.

Ideas, concerns and expectations

• Idea: “something in my ear” — a friend had the same thing and was sorted in one visit.
• Concerns: that it is the start of a stroke, like your sister; that you will not be able to drive the van for the weddings.
• Expectation: to be checked over, and sorted out in one visit like your friend if it is the same thing.

Cues to deliver, timed

• Minute 1–2: “My friend had something like this — in her ear — and they sorted her in one visit. Is that what you’ll do?”
• As you are asked to lie back: “I don’t like lying flat — will it make me sick?”
• If nothing has been said about driving by minute 7: “And the van? The weddings start in two weeks.”

If the doctor summarises and asks whether you want to add anything

• If the stroke fear has not come out: “There is one thing — my sister’s stroke started with dizziness. It’s not that, is it?”
• If it has: “I nearly came off the shop ladder last week — should I be worried about that?”

How to respond to the doctor

• If the doctor explains that loose crystals in the balance organ of the right ear are causing the spinning, that the test showed the typical pattern and nothing pointed to the brain, and that the manoeuvre moves the crystals back where they belong: relieved — “So it’s not my head.”
• If the doctor explains before the test what will happen, that the spinning is expected and brief, that you should keep your eyes open and that you can say stop: you cooperate — “all right, go on.”
• If the doctor lies you back without explaining, or without asking about your neck: “Hang on — what are you doing?” and, if ignored, “my neck’s not great, you know.”
• If the doctor says the treatment will definitely cure it: “Promise?” If told honestly — it works for most people, sometimes needs repeating, and it can come back — you accept.
• If told not to drive while you are having spins, and that the DVLA rule is about dizziness that comes out of the blue — which yours does not — and that most people with this carry on driving once it has settled: “That I can live with.” If told vaguely “you should be fine to drive”, or told you must stop driving for good: you argue.
• If offered tablets for dizziness as the main treatment: “Will they stop it?”
• If asked to repeat back the warning signs — a new headache, spinning that does not stop, trouble walking, weakness, speech or sight problems — you do so.

Do not

• Volunteer your sister’s stroke, the shop ladder or the van unless asked, or invited to add anything (apart from the timed cues).
• Use the words “BPPV”, “Epley” or “Dix-Hallpike”.
• Report any spinning, nausea or imbalance between attacks, or any hearing symptoms.

Findings to give the candidate — only if asked for

This is a procedure station. The role player can say when the room spins but cannot produce nystagmus: the examiner (or, with two people, the role player as ‘the examiner’) reads out the eye findings at the moment the candidate holds each position and looks at her eyes. Give the resting examination findings only for steps the candidate performs or asks for. (Where a separate examiner is present, the examiner reads them.)

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. Benign paroxysmal positional vertigo (NICE CKS, revised November 2025): vertigo in transient episodes, typically under a minute, provoked by specific head movements relative to gravity — lying down, turning over in bed, looking up, bending; the person is asymptomatic between attacks, commonly overestimates the duration, may have nausea and lingering light-headedness; hearing is not affected and tinnitus is not a feature. The examination at rest is normal. Perform an ear, nose and throat, cardiovascular and neurological examination to exclude other causes.
2. Dix-Hallpike (NICE CKS): be cautious if the person has a neck or back problem, or cardiovascular problems such as carotid sinus syncope, because the test turns the head and extends the neck; if in doubt, seek specialist advice or refer. Warn of transient vertigo; eyes open and looking straight ahead; sit upright with the head turned 45 degrees to one side; lie back rapidly (about 2 seconds), supporting the head and neck, until the head is extended 20–30 degrees over the end of the couch, test ear down; hold at least 30 seconds and watch the eyes for up to 30 seconds; if nystagmus appears, hold until it stops (maximum 2 minutes) and note its duration, type, direction and latency; sit up slowly; repeat on the other side. Do not repeat the positive side to demonstrate fatigue — it is unpleasant. If negative and the story is typical, repeat in a week.
3. A positive test for posterior-canal BPPV (NICE CKS): vertigo with torsional (rotatory) upbeating nystagmus — the upper pole of the eye beats towards the dependent ear, the vertical component towards the forehead; after a latent period of usually 5 to 20 seconds; building then fading, resolving within a minute of onset; a weaker reversal may occur on sitting up; the response fatigues on repetition. CKS: left-ear BPPV gives a clockwise torsion and right-ear an anticlockwise torsion (the usual teaching convention describes this as seen by the examiner facing the patient). Imaging is not needed unless the nystagmus is atypical or there are neurological symptoms.
4. Central features (NICE CKS Vertigo, revised December 2022): prolonged severe vertigo, a new headache or recent trauma, cardiovascular risk factors; focal neurological symptoms or signs; inability to stand or walk even with the eyes open; nystagmus that is direction-changing on lateral gaze, purely vertical or purely torsional, not suppressed by fixation, non-fatiguing; an atypical Dix-Hallpike — vertical nystagmus without latency or fatigue, or a direction that is not classical; a vertical correction on the alternate cover test. Not everyone with a stroke causing vertigo has focal signs. HINTS (head impulse, nystagmus, test of skew) is designed for the acute vestibular syndrome — continuous vertigo lasting days — where a normal head impulse test points to the brain; it is not a test for brief positional vertigo.
5. Epley manoeuvre (NICE CKS): caution with neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis or morbid obesity. Warn of transient vertigo; stand at the side or behind to guide the head; hold each position at least 30 seconds and until vertigo subsides; rapid movements are ideal but slow ones still work. From the Dix-Hallpike position on the affected side (head turned 45 degrees, 30 degrees dependent) → rotate the head 90 degrees to the opposite side, still extended → hold about 20 seconds and ask her to roll onto the side she is facing → rotate the head to face obliquely downwards, nose 45 degrees below horizontal → sit up sideways with the head still rotated and tilted → bring the head to the centre and the chin down 45 degrees. No positional restrictions are usually needed afterwards. Ideally done at the first presentation in primary care; the Semont manoeuvre is an alternative; Brandt–Daroff exercises can be done at home if the manoeuvre cannot be performed or is inappropriate.
6. Prognosis and follow-up (NICE CKS): most people recover over several weeks even untreated, but symptoms can last longer and recur; after a manoeuvre symptoms may improve quickly but full recovery can take days to a couple of weeks; if not settled at one week and the diagnosis is not in doubt, repeat the manoeuvre; review at four weeks if not resolved in case the diagnosis is wrong. Symptomatic drug treatment is not usually helpful. Refer to a balance specialist (ENT, audiovestibular medicine or care of the elderly, by local arrangement) if the expertise or physical safety to perform the manoeuvre is lacking, if a repeated manoeuvre has failed, if features are atypical, or if symptoms persist at four weeks; admit if vomiting prevents oral fluids.
7. Driving (NICE CKS; DVLA Assessing fitness to drive, neurological disorders, last updated 7 November 2025): advise the person not to drive while they are suffering vertigo, or if they have episodes while driving. The DVLA standard — “liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness”: Group 1 must not drive on presentation and must notify the DVLA, relicensing when symptoms are satisfactorily controlled — applies to dizziness that comes without sufficient warning to take evasive action; CKS notes that BPPV is in general not spontaneous or unprovoked and that most people with it continue to drive. Advise telling the employer where vertigo is a workplace risk — ladders, machinery, driving a vehicle — and discuss falls in the home. Mrs Moss drives a van on an ordinary licence; the advice is no driving while symptomatic, and to stop if an attack happens at the wheel.
8. Differentials (NICE CKS Vertigo): vestibular neuritis — sudden severe vertigo lasting days, gradually improving, positive head impulse test, no hearing loss; labyrinthitis — the same with hearing loss and sometimes tinnitus; Ménière’s disease — spontaneous attacks of 30 minutes to hours with fluctuating hearing loss, tinnitus and aural fullness; vestibular schwannoma — unilateral hearing loss and tinnitus; postural hypotension — light-headedness on standing rather than spinning, with a postural blood-pressure drop. Levothyroxine and hypothyroidism are not causes of positional vertigo.
9. Patient information: NHS (Vertigo) tells people to call 999 for vertigo with double vision or loss of vision, hearing loss, trouble speaking, or weakness, numbness or tingling of an arm or leg; and to seek an urgent GP appointment or NHS 111 for vertigo with a severe headache, vomiting or a high temperature. ENT UK and the Brain and Spine Foundation have leaflets on vertigo and vestibular exercises. Sudden hearing loss with vertigo is an urgent same-day problem (the NHS page lists hearing loss with vertigo under 999/A&E); the station accepts same-day contact or 999.

Where candidates lose marks at this station

• Lying her back before asking about her neck, her carotids and her back.
• Head not turned 45 degrees, not extended over the couch end, or the eyes never watched.
• Treating the wrong ear — or each Epley position held for five seconds.
• “It’s not a stroke” — with no reason given; or a 999 call for a classical positional response.
• Prochlorperazine as the treatment.
• “You should be fine to drive” — or “you must stop driving and tell the DVLA.”

Guidelines for this station

• NICE CKS — Benign paroxysmal positional vertigo (diagnosis and management, revised November 2025)
• NICE CKS — Vertigo (peripheral and central causes)
• DVLA — Assessing fitness to drive: neurological disorders (dizziness)
• NHS — Vertigo (patient information)
• ENT UK — patient information on ear and balance conditions

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-37