History Taking · Foundation · Neurology

Brief Episode of Sudden Weakness and Speech Difficulty

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 FY2 doctor in a GP surgery. Mr Derek Patel, a 67-year-old man, presented yesterday with sudden onset weakness in his right arm and slight slurring of speech lasting approximately 45 minutes, now completely resolved. He is anxious and worried about what happened. Please take a detailed history, assess his ABCD2 score, and discuss urgent management and investigation.

Background notes: PMH: Hypertension, Type 2 diabetes, Hyperlipidemia, Atrial fibrillation (recent diagnosis 2 yrs)

What this station tests

  • ABCD2 scoring within the history: calculating risk in real time to determine urgency
  • Checking anticoagulation status in a patient with known AF: aspirin alone is inadequate, and the TIA may have resulted from subtherapeutic anticoagulation
  • Communicating the urgency of the 48-hour stroke risk window without causing panic
  • Arranging same-day TIA clinic assessment per NICE guidelines: CT, carotid USS, ECG, echo, bloods
  • DVLA driving advice for TIA: minimum one month for Group 1, specialist assessment required

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 demands rapid identification of the event, risk stratification, and immediate secondary prevention. The combination of TIA and known AF is particularly high-risk and raises the critical question of whether the patient is on adequate anticoagulation. Mr Patel is 67, presenting after sudden right arm weakness and slurred speech lasting 45 minutes yesterday, now fully resolved. He has AF diagnosed 2 years ago. Open with: 'Mr Patel, tell me exactly what happened yesterday.' Time the consultation to capture the episode details quickly, then move to risk assessment.

Core approach

Characterise the episode. Sudden onset right arm weakness (could not lift arm at all) and speech slurring, lasting exactly 45 minutes, then resolving completely 'like turning a switch off.' No facial drooping, no leg weakness, no headache, no loss of consciousness. This is a left anterior circulation TIA (right arm motor deficit plus dysarthria). The sudden onset, focal negative symptoms, and complete resolution are diagnostic of TIA.

Risk stratify immediately. ABCD2 score: age >60 (1), BP likely elevated (1), unilateral weakness (2), speech disturbance (1), duration 10 to 59 minutes (1), diabetes (1) = total 7 out of 7: extremely high risk. His AF multiplies this further (5-fold stroke risk). His father had a stroke at 72, and he is now 67.

The critical management question: is he anticoagulated? He has AF diagnosed 2 years ago. Check his current medications. If he is on aspirin only, this is inadequate: AF with his CHA2DS2-VASc score mandates anticoagulation. If he is on a DOAC, check adherence. The TIA may have occurred because of subtherapeutic anticoagulation. This distinction directly affects management.

Other medications: check antihypertensive therapy, statin dose, and diabetic control. Each is a modifiable risk factor.

Closing and safety netting

Communicate urgency: 'Mr Patel, what happened yesterday was a transient ischaemic attack, which means the blood supply to part of your brain was temporarily interrupted. This is a warning. The risk of a full stroke is highest in the next 48 hours, which is why we need to act today.'

Arrange same-day TIA clinic assessment. He needs CT head (exclude haemorrhage before anticoagulation), carotid ultrasound, repeat ECG, echocardiogram, and bloods. If not anticoagulated: start DOAC today (apixaban or rivaroxaban). If on aspirin only: switch to anticoagulation. Optimise BP and statin.

DVLA: he must not drive until assessed by specialist (minimum one month for Group 1). Address his fear: his father had a stroke at 72, and he is terrified of the same fate. Provide genuine reassurance: 'With the right treatment, anticoagulation, blood pressure control, and lifestyle changes, we can significantly reduce your stroke risk.' Safety net: any recurrence of weakness, speech difficulty, or visual changes means 999 immediately.

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: Episode characterised with anatomical localisation (left anterior circulation). ABCD2 score calculated. Anticoagulation status checked. Complete medication review. Cardiovascular risk factor assessment.

Costs marks: Not characterising the episode. Not calculating risk. Not checking AF medication. Incomplete medication review.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Same-day TIA clinic referral. Appropriate investigations (CT, carotid USS, ECG, echo). Anticoagulation started or optimised. DVLA advice. Stroke symptom safety netting with 999 instruction.

Costs marks: Routine outpatient referral. Not starting anticoagulation. No DVLA advice. Vague safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining TIA as a warning in clear terms. Addressing his father's stroke fear. Communicating urgency while providing hope about risk reduction. Involving his wife in the safety plan.

Costs marks: Being alarmist without providing hope. Not acknowledging his father's history. Not explaining the rationale for urgency.

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 checking anticoagulation status. Mr Patel has AF diagnosed 2 years ago. The most important question is whether he is adequately anticoagulated. If he is on aspirin alone, his TIA is likely cardioembolic and anticoagulation is the single most important intervention. Candidates who do not check this miss the key management point.
  2. Not arranging same-day assessment. His ABCD2 score is 7/7 with AF. The 48-hour stroke risk is extremely high. Routine outpatient referral is inadequate. Candidates must arrange urgent, same-day specialist assessment.
  3. Not addressing the family history. His father had a stroke at 72, and he is 67. This is the emotional core of the consultation. Candidates who deliver the management plan without acknowledging his fear leave him feeling unheard.

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 do I approach the consultation in this transient ischaemic attack station?

TIA assessment demands rapid identification of the event, risk stratification, and immediate secondary prevention. The combination of TIA and known AF is particularly high-risk and raises the critical question of whether the patient is on adequate anticoagulation. Mr Patel is 67, presenting after sudden right arm weakness and slurred speech lasting 45 minutes yesterday, now fully resolved.

What does a strong performance look like to the examiner in this station?

Strong performances show: Episode characterised with anatomical localisation (left anterior circulation). ABCD2 score calculated. Anticoagulation status checked. Complete medication review. Cardiovascular risk factor assessment. Weak performances: Not characterising the episode. Not calculating risk. Not checking AF medication. Incomplete medication review.

What is the biggest pitfall in this transient ischaemic attack station?

Not checking anticoagulation status. Mr Patel has AF diagnosed 2 years ago. The most important question is whether he is adequately anticoagulated.

How should I prepare for transient ischaemic attack if I have never seen it in practice?

Structure beats experience here. Focus on checking anticoagulation status in a patient with known AF: aspirin alone is inadequate, and the TIA may have resulted from subtherapeutic anticoagulation. 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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