CCE-CBD-189

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between TIA and stroke?
• Prompt: What features suggest a high risk of stroke?

Q2. What are your initial management steps?

• Prompt: What pharmacological and non-pharmacological measures would you implement?
• Prompt: When would you consider urgent hospital referral?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address his concerns about stroke?
• Prompt: What lifestyle modifications should be prioritised?

Q4. What preventive measures can help reduce his risk of stroke?

• Prompt: What role do medications and lifestyle changes play in stroke prevention?
• Prompt: When should he have follow-up and ongoing monitoring?

Q5. What are the red flags that would necessitate urgent escalation of care?

• Prompt: What symptoms suggest an evolving stroke?
• Prompt: How would you manage a suspected acute stroke in general practice?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

A structured approach is required to differentiate transient ischaemic attack (TIA), stroke, and other causes of transient neurological symptoms.

Differential Diagnoses:

1. Transient Ischaemic Attack (TIA)
   • Key features: Sudden onset of neurological deficit (right-hand weakness, slurred speech) lasting <24 hours with complete resolution.
   • Risk factors present: Hypertension, smoking, borderline diabetes.
   • High risk of stroke: ABCD² score used for stratification.
2. Ischaemic Stroke (Evolving or Completed)
   • Key features: Persistent or worsening neurological deficit, even if initially transient.
   • Requires urgent neuroimaging (MRI/MRA).
3. Seizure (Todd’s Paralysis)
   • Key features: Post-ictal weakness, often preceded by abnormal movements.
   • Unlikely here due to absence of seizure history.
4. Hypoglycaemia or Other Metabolic Causes
   • Key features: Confusion, dizziness, transient neurological symptoms resolving with glucose.
   • HbA1c indicates borderline diabetes, but unlikely primary cause.

Most Likely Diagnosis:

• High-risk TIA, given the transient nature of symptoms and multiple vascular risk factors.
• Requires urgent workup to prevent stroke.

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Q2: What are your initial management steps?

Answer:

1. Immediate Actions in General Practice:

• Urgent referral to hospital (stroke unit) for brain MRI/MRA and carotid Doppler ultrasound.
• Antiplatelet therapy: Start aspirin 300mg stat (unless contraindicated).
• ECG: To rule out atrial fibrillation.

2. Risk Stratification (ABCD² Score for Stroke Risk):

• Age ≥ 60 years (+1)
• Blood pressure ≥ 140/90 (+1)
• Clinical features (speech disturbance +1, unilateral weakness +2)
• Duration ≥ 10 min but <1 hr (+1)
• Diabetes (+1)

A score ≥4 indicates high stroke risk (hospital admission required).

3. Secondary Prevention Measures:

• Blood pressure control (aim <140/90).
• Statin initiation (atorvastatin 40mg daily).
• Diabetes and lipid control.
• Smoking cessation advice and support.

4. Follow-Up Plan:

• Urgent review in 24-48 hours post-hospital assessment.
• Ongoing secondary prevention strategies.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “You likely had a transient ischaemic attack (TIA), a brief episode of reduced blood flow to the brain.”
• “This is a warning sign of a future stroke, so we must act quickly to reduce your risk.”

Treatment Plan:

• “We will send you for urgent imaging and specialist assessment.“
• “You will need blood thinners (aspirin), blood pressure control, and possibly cholesterol medication to prevent further episodes.”
• “Your smoking significantly increases stroke risk, so quitting is crucial.”

Safety-Netting:

• “If you develop weakness, slurred speech, facial droop, or confusion, seek emergency help immediately (000).“
• “Follow-up will be arranged after your specialist assessment.”

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Q4: What preventive measures can help reduce his risk of stroke?

Answer:

• Antiplatelet therapy: Long-term aspirin or clopidogrel reduces stroke risk.
• Blood pressure control: Maintain <140/90 mmHg (medication adherence essential).
• Cholesterol management: Atorvastatin 40mg daily for LDL <1.8 mmol/L.
• Smoking cessation: Referral to Quitline, nicotine replacement therapy, or pharmacotherapy (varenicline, bupropion).
• Diabetes management: Lifestyle changes ± metformin if HbA1c rises.
• Dietary modifications: DASH diet (low salt, high fibre, omega-3 fatty acids).
• Regular exercise: At least 30 minutes of moderate activity most days.

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Q5: What are the red flags that would necessitate urgent escalation of care?

Answer:

• Persistent or worsening neurological symptoms (suggesting evolving stroke).
• New-onset severe headache, vision changes, or confusion (consider intracranial pathology).
• Severe hypertension (>180/110 mmHg) requiring urgent control.
• Atrial fibrillation on ECG, requiring anticoagulation (e.g., DOACs).
• Carotid artery stenosis (>70%) on Doppler, requiring vascular referral.

Management of Suspected Acute Stroke in General Practice:

• Call 000 for urgent transfer to a stroke unit.
• Ensure blood glucose is normal (rule out hypoglycaemia).
• Do not delay stroke thrombolysis assessment in ED.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates TIA from stroke and other mimics.
• Recognises the high stroke risk and initiates urgent workup.
• Starts antiplatelet therapy and provides clear risk reduction strategies.
• Effectively communicates the urgency of the condition while addressing patient concerns.
• Recognises red flags that necessitate hospital admission.

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PITFALLS

• Failing to recognise TIA as a high-risk stroke warning.
• Not referring for urgent neuroimaging and vascular assessment.
• Delaying antiplatelet therapy initiation.
• Overlooking modifiable risk factors like smoking and hypertension.
• Not safety-netting for evolving stroke symptoms.

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REFERENCES

• RACGP Guidelines – Stroke and TIA Management
• GP Exams – Transient cerebral ischaemia

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to transient neurological symptoms.
2.2 Identifies red flag symptoms requiring urgent escalation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between TIA, stroke, and other neurological conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including secondary prevention.
4.2 Recognises when urgent hospital referral is necessary.

5. Preventive and Population Health

5.1 Educates the patient on modifiable risk factors for stroke prevention.

Competency at Fellowship Level

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