History Taking · Intermediate · Cardiovascular

Resolved Neurological Episode - Suspected TIA

Practise this PLAB 2 history taking station on Transient Ischaemic Attack. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an F Y 2 doctor in the Same Day Emergency Care unit, speaking with Mrs Margaret Wilson by phone. She is a 73-year-old woman referred by her G P following an episode of right-sided weakness and slurred speech earlier today that lasted around 45 minutes and then fully resolved. She has no current neurological symptoms and is speaking to you normally. Take a focused history to characterise the episode, assess vascular risk including A B C D 2 score, and discuss the urgent T I A clinic pathway and secondary prevention.

Background notes: PMH: Paroxysmal atrial fibrillation (on apixaban), hypertension, type 2 diabetes, hyperlipidaemia, previous TIA 2 years ago

What this station tests

  • Characterising a TIA by telephone: establishing sudden onset, negative symptoms, anatomical localisation (left MCA territory), and complete resolution without the ability to examine
  • Distinguishing TIA from mimics: actively excluding seizure (no jerking, no post-ictal confusion), migraine with aura (no marching symptoms, no headache), and hypoglycaemia (diabetic patient on metformin)
  • Uncovering medication non-adherence as the likely cause: Mrs Wilson frequently misses apixaban doses, and this must be asked about directly and specifically
  • Communicating urgency appropriately over the telephone: the highest stroke risk is in the first 48 hours, and same-day assessment is needed
  • Addressing safety concerns for a patient living alone: practical measures alongside clinical safety netting

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

TIA assessment relies almost entirely on history because, by definition, the examination is normal. The candidate's task is to characterise the episode, distinguish TIA from mimics (seizure, migraine, hypoglycaemia), assess stroke risk, and arrange urgent investigation. Mrs Wilson is 73, speaking to you by telephone after a fully resolved episode of right-sided weakness and slurred speech lasting 45 minutes this morning. She is now completely normal. Open with: 'Mrs Wilson, I understand you had an episode this morning. Can you take me through exactly what happened, from the beginning?' The telephone format means you cannot examine her, so your history must be especially thorough.

Core approach

Establish the episode in detail. At 8am while making tea, her right arm suddenly felt heavy and weak, she dropped the kettle, her right leg felt weak, and her speech became slurred. Symptoms resolved completely over 45 minutes. This is a left anterior circulation event (right-sided motor deficit plus dysphasia), anatomically consistent with left MCA territory. The sudden onset, negative symptoms (loss of function, not tingling or jerking), and complete resolution strongly favour TIA over seizure or migraine.

Actively exclude mimics. Ask about jerking movements (none, favouring TIA over seizure). Ask about preceding aura, marching symptoms, or headache (none, making migraine with aura unlikely). Ask about tongue-biting or incontinence (none). Check blood glucose status: she is diabetic on metformin, and hypoglycaemia must be excluded.

The critical PMH finding is her medication adherence. Mrs Wilson has paroxysmal AF and is prescribed apixaban 5mg twice daily, but she frequently misses her evening dose and sometimes runs out of tablets for several days before going to the pharmacy. She has definitely missed several doses in the last week. This is the most likely cause of her TIA: subtherapeutic anticoagulation in a patient with AF. You must ask about adherence directly and specifically.

She also had a TIA two years ago, making this a recurrent event. Her other medications include amlodipine, lisinopril, and atorvastatin. Check doses and adherence for all.

ICE: She is anxious and frightened but composed. She wants to know if this will happen again and whether it could become permanent. She lives alone (widowed 5 years) and is scared of having a stroke with nobody there to help.

Closing and safety netting

In any TIA station, the closing must communicate urgency without causing panic. Explain that this was most likely another TIA: 'A temporary interruption of blood supply to your brain. Everything has recovered, but this is a warning sign that needs urgent investigation.' Explain that the highest risk of stroke is in the first 48 hours after a TIA, which is why she needs to be seen today.

Arrange urgent TIA clinic assessment (same day or next day per NICE guidelines). She will need repeat brain imaging, carotid ultrasound, ECG, and blood tests. Address the anticoagulation adherence directly but without judgment: 'The blood thinner you take is very important for preventing exactly this kind of event. Missing doses significantly increases your risk. Can we talk about what makes it difficult to take regularly?' Explore practical barriers: pharmacy access, evening dose timing, pill organiser.

Safety net: 'If you develop any new weakness, speech difficulty, or visual changes, call 999 immediately, even if it seems to be getting better. Do not wait.' She lives alone, so discuss practical safety: does her daughter have a key, can she call someone, is there a personal alarm? Arrange follow-up after TIA clinic review.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for transient ischaemic attack. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Detailed episode characterisation with anatomical localisation. Active mimic exclusion: seizure, migraine, hypoglycaemia. Direct questioning about anticoagulant adherence revealing missed doses. Complete medication review. Assessment of living situation and safety for a patient who lives alone.

Costs marks: Superficial episode history without localising the deficit. Not excluding seizure or hypoglycaemia. Not checking apixaban adherence. Not assessing her living situation.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Arranging same-day or next-day TIA clinic assessment per NICE guidelines. Addressing anticoagulant non-adherence with practical solutions. Correct safety netting with specific stroke symptoms and 999 instruction. Planning appropriate investigations (imaging, carotid USS, bloods).

Costs marks: Arranging routine outpatient review instead of urgent assessment. Not addressing the adherence problem. Vague safety netting. Not considering practical safety for a patient living alone.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Adapting communication to telephone format (no visual cues, explicit verbal checking). Addressing adherence non-judgmentally: exploring barriers rather than lecturing. Acknowledging her fear of having a stroke alone. Practical safety discussion involving her daughter.

Costs marks: Being judgmental about missed medication doses. Not adapting communication style for telephone consultation. Ignoring her anxiety about living alone. Not involving her support network in the safety plan.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not asking about anticoagulant adherence. Mrs Wilson is prescribed apixaban for paroxysmal AF but frequently misses doses and has missed several in the past week. This is almost certainly why she had a TIA. Candidates who accept 'I take apixaban' without probing adherence miss the key finding and the most important intervention.
  2. Not distinguishing TIA from seizure. A 73-year-old with sudden right-sided weakness could have had a focal seizure with Todd's paresis. Candidates must ask about jerking movements, tongue-biting, incontinence, and post-ictal confusion to exclude this differential.
  3. Not communicating the urgency of same-day or next-day assessment. The risk of completed stroke is highest in the first 48 hours after TIA. Candidates who arrange routine outpatient follow-up instead of urgent TIA clinic assessment demonstrate inadequate knowledge of the NICE pathway.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the transient ischaemic attack history in this PLAB 2 station?

TIA assessment relies almost entirely on history because, by definition, the examination is normal. The candidate's task is to characterise the episode, distinguish TIA from mimics (seizure, migraine, hypoglycaemia), assess stroke risk, and arrange urgent investigation. Mrs Wilson is 73, speaking to you by telephone after a fully resolved episode of right-sided weakness and slurred speech lasting 45 minutes this morning.

What are examiners marking in this transient ischaemic attack station?

Marks are won for: Detailed episode characterisation with anatomical localisation. Active mimic exclusion: seizure, migraine, hypoglycaemia. Direct questioning about anticoagulant adherence revealing missed doses. Marks are lost for: Superficial episode history without localising the deficit. Not excluding seizure or hypoglycaemia. Not checking apixaban adherence. Not assessing her living situation.

What is the most common mistake candidates make in this transient ischaemic attack station?

Not asking about anticoagulant adherence. Mrs Wilson is prescribed apixaban for paroxysmal AF but frequently misses doses and has missed several in the past week. This is almost certainly why she had a TIA.

How do I prepare for this station if I have not managed transient ischaemic attack in clinical practice?

This station rewards process over personal experience. The skill being assessed: Distinguishing TIA from mimics: actively excluding seizure (no jerking, no post-ictal confusion), migraine with aura (no marching symptoms, no headache), and hypoglycaemia (diabetic patient on metformin). The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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