CANDIDATE INSTRUCTIONS

You are a resident year 1 doctor currently working in the Acute Medical Unit. You are about to see a patient who has presented to the hospital with sudden onset weakness.

Please take a full history from Jessica Derby, a 57-year-old woman.
At 7 minutes, the examiner will stop you to ask you some questions.

2 Minutes Reading Time

10 Minutes Station Time

Total 12 Minutes

EXAMINER INSTRUCTIONS

Timing Instructions: At 7 minutes, stop the candidate and ask the following questions:

Question 1: What are your differential diagnoses?

Answer 1:

Stroke
Transient Ischaemic Attack
Conversion Disorder
Atypical Migraine
Hypoglycaemia
Intracranial tumour
Seizure

Question 2: What is the most likely diagnosis?

Answer 2: Stroke/Transient Ischaemic Attack depending on duration of symptoms

Question 3: What is the next step in terms of management for this patient?

Answer 3: CT head to rule out a haemorrhagic stroke prior to commencing thrombolysis and thrombectomy

Stroke/Transient Ischaemic Attack (TIA)

PATIENT INSTRUCTIONS

Name: Jessica Derby
Age: 57 Years Old
Date of Birth: 29th September 1967
Location: Acute Medicine Department
Occupation: Teacher
“I was just watching the TV back home when I suddenly couldn’t move my arm and leg.”
- Onset: Weakness started 1 hour ago
- Progression: Sudden onset affecting the right arm followed by the right leg nearly immediately.
- Exacerbating Factors: Nothing makes it worse.
- Relieving Factors: Nothing makes it better.
- Associated symptoms: Feels a little nauseous and dizzy. Speech is slightly slurred. No headaches, visual changes, swallowing difficulties or loss of consciousness.
- Timing: The weakness has not gone away since onset.
- Severity: Feels so weak to the point where I just can’t walk or move my entire right side.
- Precipitating Factors : Was just watching TV as usual and cannot think of anything that may have triggered these symptoms in the first place.
- Recent illness: None.
- Recent trauma: None.
- Recent travel: None.
- Previous episodes: Never experienced this before.
- Ideas: “I think I might have a stroke!”
- Expectations: “Would I need surgery? I don’t know anything about strokes so I’m not too sure on what to expect.”
- Concerns: “I don’t want to die!”
- Bowel habits: Normal
- Urinary habits: Normal
- Appetite: Same as usual.
- Sleep: Normal.
- Weight: No change
- Pain in the chest/abdomen: None
- Mood: A little gloomy recently due to financial stress.
- Dizziness: None
- Loss of balance: None
- Fever: None
- ENT: Normal
- Cardiology: Normal
- Respiratory: Normal
- Ophthalmology: No visual changes
Previous hospital admissions: Hospitalized for a heart attack 10 years ago.
Previous surgeries: Percutaneous Coronary Intervention (PCI) 10 years ago.
Medical conditions:
- Type 2 Diabetes Mellitus
- Myocardial Infarction
- Hypercholesterolaemia
Medications:
- Metformin and Gliclazide for T2DM
- Atorvastatin for hypercholesterolaemia
- Other tablets I take after I had my heart attack: Aspirin, Clopidogrel, Ramipril and Atenolol.
Over the counters:
- None
Allergies:
- None
Grandmother had a stroke when she was younger. High blood cholesterol runs in the family.
- Smoking: 15-20 cigarettes a day. Have been smoking for the past 20 years.
- Alcohol: Very rarely
- Recreational drugs: “Tried marijuana once when I went to college.”
- Diet: Usually fast food, or takeaways. I rarely cook.
- Exercise: Nothing regular
- Ill contacts: No one around me were ill recently
- Home: Lives with partner in a terraced house.
- Active Daily Living: Usually mobile and able to perform daily functions normally.

MARK SCHEME

Introduction

Introduces self with full name and role

Washes hand

Identifies patient with at least 2 identifiers

Explains purpose of consultation and gains consent

Ideas, Expectations & Concerns

Explore ideas, concerns, and expectations

Presenting Complaint

Establishes presenting complaint on initial presentation

History of Presenting Complaint

Onset ℹ

Enquiring about the onset of symptoms as well as time since symptom onset can help determine whether the patient is a suitable thrombolysis candidate

Progression

Exacerbating Factors

Relieving Factors

Associated Symptoms ℹ

Asking about associated symptoms can give clues on the location of the stroke, severity of it and warns of any potential dangers associated with the stroke. For example, a stroke affecting higher cognition, vision and motor symptoms may point towards a total anterior circulation stroke. On the other hand, a patient with swallowing difficulties associated with the stroke may need to be put Nil-by-mouth to prevent potential aspiration pneumonia or choking.

Timing

Severity

Precipitating Factors

Previous Episodes

Systems Review

Systems Review (at least six) ℹ

A complete systems review is necessary to rule out other differential diagnoses. Asking about loss of balance may point to a cerebellar stroke. Loss of consciousness may be related to a seizure or even hypoglycaemia. Asking about recent mood may, though rare, point towards conversion disorder as a differential.

Asked about recent illness

Asked about recent trauma

Past Medical History

Previous hospital admissions

Previous surgeries

Any known past medical conditions ℹ

Enquiring about past medical conditions allows us to screen the patient’s comorbidities which may have contributed to their presentation. For example, this patient has hypercholesterolaemia, type 2 diabetes mellitus on top of a previous myocardial infarction, all of which are highly associated with cerebrovascular accidents.

Drug History

Asked about medication use ℹ

Asking about the patient’s drug history may give clues as to the cause of the stroke i.e. this patient’s antiplatelet use for his myocardial infarction may have resulted in a haemorrhagic stroke.

Ask for allergies and the allergic reaction

Establish any over the counter medication use

Family History

Establish any relevant family history ℹ

A full family history is vital as the common metabolic (diabetes and hypercholesterolaemia) and vascular (myocardial infarction and cerebrovascular accidents) conditions are typically familial.

Social History

Explore smoking status ℹ

Smoking is a huge contributing factor to CVAs

Explore alcohol use

Explore recreational drug use

Explore diet ℹ

A diet consisting of fatty, sweet and oily food may cause hypercholesterolaemia, which may ultimately cause a stroke

Ask about exercise

Explore living situation

Ask about patient’s occupation ℹ

Exploring the patient’s social history and occupation is important as part of post-acute stroke management. For example, an HGV driver may need to be put off work because of their stroke and inform the DVLA. In patients with stairs at home, occupational health review may be needed to make necessary adjustments to their homes for the sake of their convenience at home post-stroke.

Questions

Identifies at least 3 appropriate differential diagnoses

Identifies the most likely diagnosis

Identifies CT scan as priority ℹ

A CT scan in the first instance is extremely important to differentiate between an ischaemic and a haemorrhagic stroke. This is because thrombolysis which is used to treat an ischaemic stroke is counterproductive and may exacerbate a haemorrhagic stroke, making it extremely important to first differentiate the type of stroke to allow the most appropriate management plan to be made.

Patient Scores

Rate how well the candidate has performed from a patient’s perspective out of 5 points.

Enter Your Score Here: /47

SCORE GUIDE

High Pass: > 38

Pass: > 29

Borderline Pass: 24 – 29

Fail: < 24

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Weakness

CANDIDATE INSTRUCTIONS

EXAMINER INSTRUCTIONS

PATIENT INSTRUCTIONS

MARK SCHEME

SCORE GUIDE

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