CCE-CBD-164

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your working diagnosis, and how would you differentiate between types of stroke?

• Prompt: What signs suggest an ischaemic stroke?
• Prompt: How would you rule out haemorrhagic stroke in this setting?
• Prompt: What is the significance of the time of onset?

Q2. Outline your immediate management plan in this rural general practice setting.

• Prompt: What stabilisation measures will you initiate?
• Prompt: How will you arrange for urgent imaging and specialist input?
• Prompt: What factors will determine suitability for thrombolysis?

Q3. How will you address secondary prevention of stroke for John?

• Prompt: What long-term medications will you recommend?
• Prompt: What lifestyle modifications are appropriate?
• Prompt: How will you coordinate care for rehabilitation in a rural setting?

Q4. How would you explain the diagnosis and management plan to John and his family?

• Prompt: How do you communicate risk and prognosis sensitively?
• Prompt: How will you involve family in decision-making and support?
• Prompt: How will you manage the challenges posed by John’s rural location?

Q5. What are the potential complications of stroke that you should monitor for in this acute setting?

Prompt: How would you monitor and manage these complications in a rural setting?

Prompt: What neurological, cardiovascular, and respiratory complications do you need to consider?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your working diagnosis, and how would you differentiate between types of stroke?

Answer:
My working diagnosis is acute ischaemic stroke, most likely affecting the left middle cerebral artery (MCA) territory, given the sudden-onset right-sided weakness, facial droop, and expressive aphasia. The onset was within the last 45 minutes, placing this event within the critical therapeutic window for potential thrombolysis or thrombectomy.

Differentiating Stroke Types:

• Ischaemic stroke is characterised by sudden-onset focal neurological deficits without associated headache, vomiting, or decreased consciousness in most cases.
• Haemorrhagic stroke often presents with sudden headache (“thunderclap”), nausea/vomiting, raised intracranial pressure signs, altered consciousness, and can have similar focal deficits.

Key Differentiating Strategies:

• Neuroimaging (CT head without contrast) is essential to exclude haemorrhage. It is the gold standard initial investigation.
• Blood pressure elevation is common in both types, but extremely high readings are more suggestive of haemorrhagic stroke.
• Onset of symptoms: Both are acute, but rapid deterioration is more common in haemorrhage.

Significance of Onset Time:

• Critical to establish because thrombolysis (Alteplase) is recommended within 4.5 hours of symptom onset, and mechanical thrombectomy is possible within 6-24 hours depending on imaging findings.
• The “last known well” time anchors eligibility for acute interventions.

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Q2: Outline your immediate management plan in this rural general practice setting.

Answer:

Immediate Priorities:

1. Airway, Breathing, Circulation (ABCs):
   • John is conscious, airway patent, SpO₂ 98%, so no immediate airway compromise.
   • Monitor respiratory status, cardiac rhythm, BP.
2. Blood Glucose: Already checked—normal at 6.0 mmol/L.
3. IV Access and Fluids:
   • Establish large bore IV access.
   • Avoid hypotonic fluids; normal saline if required.
4. Blood Pressure Management:
   • Maintain systolic BP <185 mmHg if proceeding to thrombolysis; otherwise permissive hypertension (up to 220/120) if not eligible.

Urgent Actions:

• Immediate transfer to the regional stroke unit with CT facilities via the Royal Flying Doctor Service or local ambulance.
• Liaise with Stroke Neurologist via telestroke service for real-time consultation.

Investigations Pre-Transfer:

• ECG (normal), blood tests (including FBC, electrolytes, coagulation studies), cross-match if needed.

Criteria for Thrombolysis:

• Onset <4.5 hours, no contraindications (e.g., recent surgery, bleeding disorders), CT confirms no haemorrhage.

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Q3: How will you address secondary prevention of stroke for John?

Answer:

Long-term Pharmacological Measures:

• Antiplatelet therapy: Continue aspirin 100 mg or consider dual antiplatelet if advised by stroke team.
• Statin therapy: Continue atorvastatin; aim for LDL <1.8 mmol/L.
• Blood pressure control: Titrate perindopril, aim for BP <140/90 mmHg.
• Consider adding a thiazide diuretic or calcium channel blocker if BP remains elevated.

Lifestyle Interventions:

• Smoking: Already ceased; reinforce abstinence.
• Diet: Low sodium, heart-healthy diet, consider dietician input.
• Exercise: Progressive mobilisation and physiotherapy as tolerated.
• Weight management: Target BMI <25 kg/m².

Coordinated Care:

• GP Management Plan (GPMP) and Team Care Arrangements (TCA) for multidisciplinary care.
• Referral to stroke rehabilitation: Consider community-based or inpatient, factoring in rural access.
• Driving and work: Counsel on fitness to drive (not permitted for minimum 4 weeks), occupational therapy for return-to-work planning.

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Q4: How would you explain the diagnosis and management plan to John and his family?

Answer:

Communication:

• Use simple, clear language, acknowledging John’s aphasia—speak slowly, use gestures.
• Confirm understanding via yes/no questions or writing if possible.

Explanation:

• “John has had a stroke, which is a sudden blockage of blood flow to part of the brain. This is why you are feeling weak on the right side and having trouble speaking.”

Management Plan:

• Emphasise urgency: “We need to act quickly to reduce the risk of long-term damage.”
• Explain transfer for urgent brain scan and potential clot-busting treatment.

Prognosis:

• Be honest but hopeful: “The sooner we treat, the better the chance for recovery.”

Family Involvement:

• Discuss their role in assisting John with rehabilitation and recovery.
• Explore their concerns about John’s ability to live independently.

Rural Challenges:

• Plan for telehealth consultations, support services, and transport to rehabilitation facilities.

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Q5: What are the potential complications of stroke that you should monitor for in this acute setting?

Answer:

Neurological Complications:

• Progression of stroke—expanding infarct, haemorrhagic transformation.
• Seizures—less common but possible.
• Raised intracranial pressure—signs of declining consciousness.

Cardiovascular:

• Arrhythmias, particularly atrial fibrillation.
• Myocardial infarction, particularly in older patients.

Respiratory:

• Aspiration pneumonia—due to impaired swallowing (dysphagia screen needed).
• Hypoventilation—monitor oxygenation.

Other:

• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)—immobility.
• Pressure sores—prolonged immobility.

Monitoring:

• Hourly neurological observations (AVPU, NIHSS).
• Frequent BP, HR, SpO₂ checks.
• Ensure input/output charts to assess hydration.

In a rural setting:

• Limited access to high-dependency units may necessitate early transfer.
• Close coordination with the stroke team and retrieval services.

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SUMMARY OF A COMPETENT ANSWER

• Correct diagnosis of acute ischaemic stroke with appropriate differentiation.
• Urgent management with ABCs, neuroimaging, and stroke team liaison.
• Secondary prevention including medications and lifestyle changes.
• Effective communication with patient and family, considering aphasia and rural challenges.
• Monitoring and managing complications, particularly neurological and respiratory.

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PITFALLS

• Failure to establish time of onset accurately.
• Delaying transfer or imaging for unnecessary in-house tests.
• Inappropriate BP lowering before confirming eligibility for thrombolysis.
• Underestimating rehabilitation needs in rural settings.
• Poor communication ignoring the patient’s aphasia and emotional needs.

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REFERENCES

• Stroke Foundation Clinical Guidelines
• RACGP Red Book, 10th Edition
• Australian Stroke Foundation
• National Stroke Audit (2022)

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Rationally selects, justifies, and interprets relevant investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.
4.2 Provides appropriate emergency care.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses practice systems effectively and safely.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially life-threatening or serious conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural healthcare challenges.

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Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD