Chioma Eze
Age: 34 years old female
Full Case
Patient’s Data
Past medical history
- Normal vaginal delivery 7 months ago
Drug and Allergy History
- Nil
Recent notes/consultation
- Nil
Patient has booked an urgent telephone consultation to discuss ongoing concerns.
Patient's Story (Role player’s brief)
Patient’s Story
You are Chioma Eze, a 34-year-old female. You have booked an urgent telephone consultation to discuss episodes of dizziness that you have been experiencing over the past 4 days.
Opening statement: “Hi doctor… I’ve been feeling really dizzy for the past few days — it’s like I’m drunk or the room is spinning. It’s not getting better, and I just don’t know what’s going on
ONLY DISCLOSE IF ASKED:
- The dizziness feels like a spinning sensation (i.e. vertigo).
- The dizziness started spontaneously and is present constantly, even when your head is still.
- However, it is not as severe when you remain still. Symptoms are worsened by head movement but not triggered by it — the dizziness is already ongoing, and changes in head position simply exacerbate it.
- You experienced flu-like symptoms approximately 3 days before the dizziness began.
- You feel nauseous and have vomited several times.
- You do not have any hearing loss or tinnitus.
Social History: You are a single parent with two children (aged 7 months and 2 years), both fully dependent on you.
You are struggling to care for them due to the constant dizziness.
You moved to the UK from Nigeria two years ago and do not have close family or social support nearby. You work as an IT professional but are currently on maternity leave.
You drive but not driving currently due to dizziness.
Idea: You have never had this type of dizziness before and don’t know what might be causing it.
Concern: You’re worried about a brain tumour, as your aunt had similar symptoms and was later diagnosed with one. You are also worried that your dizziness is impacting your ability to care for your children, and you do not have anyone to look after them.
Expectation: You would like the doctor to prescribe some medication and arrange a brain scan to rule out anything serious.
Questions for the doctor
If the doctor offers an anti-sickness medication, ask: “Will this affect my baby?”
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Clarify the nature of the dizziness – light-headedness vs. spinning sensation (to differentiate between vertigo and presyncope)
- Ask when the symptoms started
- Ask whether the dizziness is constant or intermittent (constant vertigo may suggest central causes such as stroke, or peripheral causes like vestibular neuronitis or labyrinthitis; intermittent vertigo is more typical of benign paroxysmal positional vertigo [BPPV])
- Ask how long each episode of dizziness/vertigo lasts (BPPV typically causes brief, transient episodes lasting less than 1 minute, often triggered by changes in head position, with complete resolution between episodes)
- Ask for associated nausea and vomiting
- Ask if dizziness is aggravated by head movement (in vestibular neuronitis and labyrinthitis, dizziness is already present but becomes worse with head movement — it is worsened, not triggered; in contrast, BPPV causes dizziness that is triggered by specific head movements and resolves between episodes)
- Ask about tinnitus and hearing loss (hearing loss is present in Meniere’s disease or labyrinthitis)
- Ask about any recent viral illness or flu-like symptoms (common trigger for vestibular neuritis or labyrinthitis)
- Screen for neurological red flags: headache, blurred vision, slurred speech, weakness or numbness in any part of the body (to rule out central causes such as stroke, TIA, or space-occupying lesions)
- Ask whether she has experienced any falls as a result of dizziness (to assess safety and risk of injury)
- Explore how she is coping at home, particularly with the children
- Ask about lifestyle and social history, including smoking, alcohol intake, and occupation
- Ask if she drives or operates machinery at home or work to assess risks related to her safety and fitness to drive
Give a diagnosis of vestibular neuronitis
Example of explanation to patient
Chioma, based on everything you’ve described and the timing of your symptoms after a recent viral illness, this sounds very much like a condition called vestibular neuronitis. That simply means that one of the nerves in your inner ear – the vestibular nerve, which helps you with balance – has become inflamed, usually after a viral infection. This inflammation causes dizziness or a spinning feeling (which we call vertigo), problems with balance, and often nausea or even vomiting. The good news is that it usually gets better on its own within a few weeks, although the symptoms can be quite disabling in the meantime.
You mentioned that you’re worried this might be something serious like a brain tumour, especially given your family history. It’s completely understandable to have that fear when you’re feeling so unwell.
The good news is that based on what you’ve told me; a brain tumour is unlikely. Typically, with something like a tumour, we would expect to see other signs, for example, persistent headaches, blurry vision, weakness, or problems with speech. You’ve told me you’re not experiencing any of these, which is really reassuring.
However, would it be alright if I arrange for you to come in for a face-to-face appointment today so I can check a few things, including examining the nerves of your body, check your blood pressure, have a look inside your ears, and examine the back of your eyes, just to make sure we’re not missing anything else?
Chioma, in terms of helping you feel better, we can start a short course of medication called cyclizine. It’s used to relieve symptoms like dizziness and nausea, and I’d recommend taking it regularly up to three times a day for about 3 days. It’s important to use it only for a short time and that’s because your body needs time to naturally adjust and recover from the problem in your inner ear. If we rely on the medication for too long, it can actually slow down that natural recovery, and you might end up feeling dizzy for longer overall.
You mentioned you’re breastfeeding, and I completely understand your concern about whether the medication could affect your baby. Cyclizine can pass into breast milk, but the amounts are small, and it’s not known to be harmful. That said, I would still advise you to keep an eye on your baby. If you notice any unusual drowsiness, lethargy, or anything that doesn’t feel right, please seek urgent medical advice straightaway.
If you’re worried, another option is to express some breast milk before starting the medication, so you have a supply ready while you see how your baby responds. That can give you some flexibility and peace of mind.
Make sure you’re staying well hydrated, and try to rest as much as possible — I know that’s incredibly hard with two little ones at home. Do you have any friends, family, or neighbours who might be able to help look after the children while you recover? If not, we could look into options like paid childminders or help through local support services or social prescribers , just so you can have the space to rest and recover safely.
Also, while you’re feeling dizzy, please avoid driving or operating any machinery, as this could put you or others at risk.
If your symptoms get worse, or you develop new symptoms such as weakness on one side of your body, blurred vision, severe headache, or if things are not clearly improving or have not resolved after a week, please don’t wait, seek urgent medical advice straightaway.
Management
Management
- Offer a face-to-face appointment to examine the ears, check blood pressure, assess cranial and peripheral nerves, and perform the head impulse test (ensure no neck issues before this).
- Prescribe a short course of antiemetics such as cinnarizine or cyclizine to relieve nausea and vomiting.
- Advise that antiemetics should be used for a maximum of 3 days to avoid interfering with the body’s natural vestibular compensation.
- Explain that cyclizine and cinnarizine are present in breast milk in small amounts but are not known to be harmful.
- Advise her to monitor the baby for signs of drowsiness or lethargy and to seek urgent medical advice if any concerns arise.
- Suggest expressing breast milk before starting medication as a precaution if she is worried.
- Encourage adequate fluid intake to prevent dehydration and support recovery.
- Ask if she has friends, relatives, or neighbours who can assist with childcare while she is unwell.
- If no informal support is available, offer the option of arranging paid childminders or referring to the social prescriber to explore any additional local support services that may be available to assist her at home.
- Advise avoiding driving or operating machinery while experiencing dizziness.
- Offer a follow-up review in one week to monitor progress and recovery.
- Provide safety-netting advice: if symptoms worsen, persist beyond one week, or if new symptoms such as visual changes or weakness develop, she should seek urgent medical attention .
Learning point from this station:
Vestibular neuronitis is a common peripheral cause of vertigo, typically occurring after a viral infection. It presents with sudden-onset, constant dizziness or vertigo, often accompanied by nausea and imbalance, but without hearing loss. In contrast, labyrinthitis involves similar vertigo but is associated with hearing loss and/or tinnitus due to involvement of the cochlear component of the inner ear.
One key distinguishing feature is that in vestibular neuronitis, the dizziness is constant but worsens with head movement — it is exacerbated, not triggered, by positional changes. This is different from BPPV, another peripheral cause, where dizziness is episodic, brief (usually <1 minute), and is directly triggered by specific head movements.
It’s also important to differentiate peripheral vertigo from central causes (e.g. stroke, tumour), which often present with additional neurological symptoms such as:
- New-onset headache
- Visual changes or diplopia
- Slurred speech
- Focal weakness or numbness
In addition, there may be history of recent head trauma and cardiovascular risk factors, which should raise concern for a possible posterior circulation stroke
A careful history and focused neurological examination are essential to distinguish between benign, self-limiting conditions like vestibular neuronitis and more serious central causes requiring urgent attention.