CCE-CE-189

CASE INFORMATION

Case ID: TIA-007
Case Name: John Patterson
Age: 68
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K89 (Transient Cerebral Ischaemia)​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations
1.2 Explains diagnosis and management clearly
1.5 Uses clear, structured communication to discuss risk and urgency
2. Clinical Information Gathering and Interpretation2.1 Takes a thorough history focusing on neurological symptoms, duration, and risk factors
2.2 Identifies key examination findings to differentiate TIA from stroke mimics
3. Diagnosis, Decision-Making and Reasoning3.1 Recognises key features of a transient ischaemic attack (TIA)
3.2 Differentiates TIA from stroke and other differentials (e.g., seizure, migraine, syncope)
4. Clinical Management and Therapeutic Reasoning4.2 Develops an immediate and long-term management plan, including secondary prevention
4.3 Ensures appropriate investigations and urgent referral
5. Preventive and Population Health5.1 Identifies and addresses modifiable vascular risk factors
5.3 Provides lifestyle advice for stroke prevention
6. Professionalism6.2 Maintains patient confidentiality and ensures appropriate duty of care
7. General Practice Systems and Regulatory Requirements7.3 Ensures appropriate documentation, safety netting, and follow-up in line with guidelines
9. Managing Uncertainty9.1 Recognises the urgency of TIA and when hospital referral is required
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag symptoms requiring immediate escalation of care

CASE FEATURES

  • 68-year-old male presenting with sudden onset of left arm weakness and slurred speech lasting 15 minutes, resolved on arrival.
  • No residual symptoms, but worried about what happened.
  • Hypertensive, ex-smoker, borderline diabetic, but not on any regular medication.
  • Needs urgent assessment for a transient ischaemic attack (TIA) and secondary prevention.
  • Risk stratification using the ABCD² score and discussion on urgent hospital referral.
  • Patient education on stroke symptoms, risk factors, and future prevention.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform a physical examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

John Patterson, a 68-year-old retired accountant, presents to your general practice accompanied by his wife after experiencing a sudden episode of left arm weakness and slurred speech earlier today. The symptoms lasted around 15 minutes and then completely resolved. His wife was with him at the time and confirms that he was alert and able to speak normally shortly after.

PATIENT RECORD SUMMARY

Patient Details

  • Name: John Patterson
  • Age: 68
  • Gender: Male
  • Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • None currently

Past History

  • Hypertension (diagnosed 5 years ago, not well controlled)
  • Borderline diabetes (last HbA1c 6.4%)
  • No previous cardiovascular or neurological events

Social History

  • Retired accountant, lives with wife

Family History

  • Father had a stroke at age 72
  • No history of diabetes or cardiac disease

Smoking & Alcohol

  • Ex-smoker, quit 10 years ago
  • Minimal alcohol intake

Vaccination and Preventive Activities

  • Up to date with vaccinations

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, earlier today my left arm felt weak, and my wife said my speech was slurred. It only lasted about 15 minutes, and I feel fine now. Should I be worried?”

General Information

(Freely Shared if Asked Open-Ended Questions)

  • Earlier today, while having lunch at home, I suddenly felt weak in my left arm.
  • I couldn’t grip my fork properly, and my wife noticed my speech sounded a bit slurred.
  • The weakness and slurred speech lasted about 15 minutes and then completely resolved.
  • No confusion, dizziness, headache, vision loss, or numbness.

Specific Information

(Only If Asked Targeted Questions)

Background Information

  • I could still move my arm, but it felt weak.
  • I did not have any chest pain, shortness of breath, or palpitations.
  • This has never happened before.
  • My wife was very worried and wanted to call an ambulance, but I felt fine afterward, so I said no.

Symptom Progression and Details

  • The episode started suddenly and ended suddenly within 15 minutes.
  • I have no current weakness, speech issues, or other symptoms.
  • I have been feeling normal since it happened.
  • No falls, trauma, or fainting before the episode.

Medical History and Risk Factors

  • Diagnosed with high blood pressure 5 years ago, but I haven’t been taking medication regularly.
  • Told I was borderline diabetic a year ago but never followed up.
  • Smoked a pack a day for 30 years, but quit 10 years ago.
  • No previous stroke or heart problems.
  • No history of atrial fibrillation or blood clots.
  • Father had a stroke at age 72.

Lifestyle and General Health

  • Diet isn’t great, I eat a lot of processed food.
  • I don’t exercise regularly—just walking around the house.
  • Drink alcohol occasionally (1-2 drinks per week).
  • No drug use.
  • Haven’t had a GP check-up in years.

Emotional Cues & Reactions

  • Minimises the event initially: “I feel fine now, so I don’t think it’s anything serious.”
  • Wife is much more concerned, interrupts to say: “Doctor, it really scared me. I think something is wrong.”
  • A little defensive about health habits, especially when asked about blood pressure medication and lifestyle.
  • Slightly resistant to the idea of hospital referral, saying: “Do I really need to go? Can’t we just do some tests here?”
  • If the doctor explains the risks well, he gradually becomes more willing to consider urgent assessment.
  • Expresses relief if reassured that early action can prevent a stroke.

Questions the Patient Might Ask

  1. “Was this a stroke?”
  2. “Do I really need to go to the hospital if I feel fine?”
  3. “What happens if I don’t do anything about it?”
  4. “What tests do I need?”
  5. “How can I stop this from happening again?”
  6. “Will I have to take medication for the rest of my life?”

How to Play the Role

Opening Scene (First Few Minutes)

  • Appear calm but slightly puzzled about why his wife is so worried.
  • Speaks normally, showing no obvious neurological deficits now.
  • Maintains good eye contact but shrugs off concerns at first.

If the Doctor Asks About Symptoms Thoroughly:

  • Provide clear details, emphasising that everything resolved within 15 minutes.
  • Start considering that it might have been serious if the doctor explains the risks well.

If the Doctor Dismisses the Event as Unimportant:

  • Look slightly frustrated, as the wife insists: “But something definitely happened!”
  • Say, “I just want to make sure I don’t need to worry about this later.”

If the Doctor Recommends Hospital Referral:

  • Hesitant at first, asks: “Is that really necessary?”
  • If the doctor explains the risk of stroke, gradually becomes more accepting.
  • More willing to go if told that early treatment prevents major strokes.

If the Doctor Discusses Lifestyle Changes:

  • Defensive at first, saying: “I already quit smoking. I don’t think my diet is that bad.”
  • More open if the advice is practical and tailored (e.g., simple exercise and diet changes).
  • Wants to know if he will need lifelong medications.

Ending the Consultation (Final Reaction Depending on the Doctor’s Approach)

If the Doctor Provides a Clear Plan and Explains the Urgency Well:

  • Looks more serious and thoughtful.
  • Says, “Okay, I’ll go to the hospital. I don’t want to take any chances.”
  • Asks about follow-up and what tests will be done.

If the Doctor Is Unclear or Dismissive:

  • Looks unconvinced and unsure.
  • Says, “I think I’ll just keep an eye on it for now.”
  • May delay seeking medical attention, increasing stroke risk.

Key Features for the Examiner to Observe

  • How well the candidate takes a structured history, focusing on neurological symptoms, risk factors, and red flags.
  • Ability to recognise a likely TIA, requiring urgent referral and secondary prevention.
  • Clear communication, explaining why a TIA is a warning sign for stroke.
  • Discussion of risk factor modification, including blood pressure control, diabetes management, and lifestyle changes.
  • Ability to manage patient reluctance to seek urgent care.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a detailed history of the neurological episode, focusing on symptoms, duration, and risk factors.

The competent candidate should:

  • Elicit key details of the episode, including:
    • Exact onset, duration, and resolution of symptoms.
    • Nature of symptoms (weakness, slurred speech).
    • Associated symptoms (vision changes, dizziness, confusion).
    • Any similar past episodes.
  • Assess red flag features, including:
    • Persistent neurological deficit (suggests stroke, not TIA).
    • Headache, nausea, or altered consciousness (consider alternative causes).
  • Evaluate risk factors for cerebrovascular disease, including:
    • Hypertension, diabetes, smoking, atrial fibrillation, past stroke/TIA, and hyperlipidaemia.
  • Clarify medication and lifestyle history, including:
    • Medication adherence for hypertension and diabetes.
    • Exercise levels, diet, alcohol use, and smoking history.

Task 2: Formulate an appropriate differential diagnosis, considering stroke mimics.

The competent candidate should:

  • Recognise TIA as the most likely diagnosis, based on:
    • Sudden onset, focal neurological deficit, and resolution within 15 minutes.
  • Differentiate TIA from other causes, including:
    • Ischaemic stroke (if persistent deficit).
    • Migraine aura (positive sensory symptoms, gradual progression).
    • Seizure/postictal weakness (Todd’s paresis).
    • Hypoglycaemia (check blood glucose).
    • Vestibular disorders (if dizziness is predominant).

Task 3: Explain the likely diagnosis of TIA, including risk stratification and the need for urgent assessment.

The competent candidate should:

  • Explain what a TIA is: a temporary interruption of blood flow to the brain, resolving within 24 hours, but a warning sign of future stroke.
  • Use simple language: “Your brain had a temporary shortage of blood supply, which caused your symptoms. Even though you feel fine now, this could be a warning sign of a future stroke.”
  • Calculate the ABCD² score to stratify risk:
    • Age ≥ 60 (1 point).
    • Blood pressure ≥ 140/90 mmHg (1 point).
    • Clinical features (unilateral weakness = 2 points, speech disturbance = 1 point).
    • Duration (≥ 60 min = 2 points, 10–59 min = 1 point).
    • Diabetes (1 point).
  • Explain why urgent referral is needed:
    • High risk of stroke in the next 48 hours.
    • Need for urgent imaging (brain MRI/CT) and carotid Doppler.
    • Possible need for anticoagulation if atrial fibrillation is present.

Task 4: Develop a management plan, including urgent referral, secondary prevention, and patient education.

The competent candidate should:

  • Arrange urgent hospital assessment, including:
    • Emergency department referral or TIA clinic (within 24 hours).
    • Blood tests, ECG, carotid ultrasound, and brain imaging.
  • Initiate secondary prevention, including:
    • Blood pressure control (starting antihypertensives if indicated).
    • Statin therapy if lipid profile is abnormal.
    • Antiplatelet therapy (aspirin 300mg or clopidogrel) if no contraindications.
    • Diabetes control and lifestyle changes.
  • Provide patient education, including:
    • Stroke symptoms (FAST: Face, Arm, Speech, Time) and when to seek emergency care.
    • Lifestyle modifications: smoking cessation, diet, regular exercise.
    • Need for regular follow-up and adherence to treatment.

SUMMARY OF A COMPETENT ANSWER

  • Thorough history-taking, covering neurological symptoms, duration, and risk factors.
  • Clear differential diagnosis, distinguishing TIA from stroke and other mimics.
  • Accurate risk stratification, using ABCD² score to guide urgency.
  • Urgent hospital referral, explaining why immediate assessment is required.
  • Comprehensive secondary prevention, addressing hypertension, diabetes, and lifestyle.
  • Empathetic and clear communication, ensuring the patient understands the risk of stroke.

PITFALLS

  • Failing to take a detailed history, missing key risk factors or symptoms.
  • Not considering stroke mimics, such as seizures or migraine aura.
  • Underestimating urgency, delaying referral when high-risk features are present.
  • Overlooking secondary prevention, failing to address modifiable risk factors.
  • Not explaining the risk clearly, leading to patient reluctance to seek care.

REFERENCES

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.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history focusing on neurological symptoms, duration, and risk factors.
2.2 Identifies key examination findings to differentiate TIA from stroke mimics.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises key features of a transient ischaemic attack (TIA).
3.2 Differentiates TIA from stroke and other differentials.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an immediate and long-term management plan, including secondary prevention.
4.3 Ensures appropriate investigations and urgent referral.

5. Preventive and Population Health

5.1 Identifies and addresses modifiable vascular risk factors.
5.3 Provides lifestyle advice for stroke prevention.

9. Managing Uncertainty

9.1 Recognises the urgency of TIA and when hospital referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag symptoms requiring immediate escalation of care.

Competency at Fellowship Level

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