PLAB 2 TIA Station: Aspirin 300 mg, 24-Hour Referral & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Transient ischaemic attack
  Sudden focal neurological deficit (face, arm, speech) of vascular origin that resolves completely, usually within minutes to an hour. The working diagnosis the station is testing.
• Stroke
  The same deficit but persisting. If symptoms have not fully resolved, treat as an acute stroke - call the stroke team and arrange immediate CT, not a 24-hour referral.
• Hypoglycaemia
  Can mimic focal deficits, especially in a patient on insulin or a sulfonylurea. Always check a capillary glucose - a classic stroke mimic.
• Migraine with aura
  Spreading, positive visual or sensory symptoms over minutes, often with headache and a prior history. Slower onset than a TIA.
• Focal seizure
  Positive motor or sensory symptoms, sometimes with post-ictal weakness (Todd's paresis). Look for a seizure history and the nature of onset.
• Syncope or vestibular causes
  Global, non-focal symptoms (lightheadedness, isolated vertigo) point away from a TIA - although posterior-circulation events can present with vertigo.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open the consultation

   Set the tone, then take a precise history of the episode.

   • Wash hands, greet, introduce yourself with name and grade.
   • Confirm name and date of birth.
   • Acknowledge that the episode would have been frightening.

2. 2. Take a precise history of the episode

   Onset, the exact deficit, and crucially that it fully resolved.

   • What exactly happened - face droop, arm or leg weakness, speech difficulty, visual loss?
   • Sudden onset? How long did it last? Has it completely resolved now?
   • One-sided? What were they doing when it started?
   • Any headache, loss of consciousness, confusion, or seizure activity?

3. 3. Screen mimics

   Rule out the common stroke mimics before committing.

   • Diabetes and hypoglycaemia risk - any missed meals, insulin or sulfonylureas.
   • Migraine history and the character of any visual symptoms.
   • Seizure history.

4. 4. Sweep vascular risk factors

   A clean risk-factor pass is high-yield and shapes secondary prevention.

   • Hypertension, diabetes, high cholesterol.
   • Smoking and alcohol.
   • Atrial fibrillation or palpitations.
   • Previous TIA or stroke, ischaemic heart disease.
   • Family history of stroke; the combined oral contraceptive pill.

5. 5. Complete the history

   Background, medications and the patient's perspective.

   • Past medical history, medications (including anticoagulants and antiplatelets), allergies.
   • Occupation - especially whether they drive for a living.
   • Ideas, concerns and expectations.

6. 6. Request examination findings

   Confirm full recovery and look for a source.

   • Full neurological examination - expect it to have returned to normal.
   • Blood pressure in both arms; pulse for atrial fibrillation.
   • Heart sounds and carotid auscultation for bruits.
   • Capillary blood glucose.

7. 7. Request investigations

   Bloods, an ECG for AF, and specialist-led imaging.

   • Bloods - FBC, U&Es, glucose, lipids, clotting.
   • ECG - look for atrial fibrillation.
   • Carotid Doppler and brain imaging (MRI preferred) are usually arranged by the specialist clinic.

8. 8. Start immediate secondary prevention

   The safety-critical drug action - do not wait for the clinic.

   • Aspirin 300 mg immediately, unless contraindicated.
   • If the patient is already anticoagulated or has AF, discuss with the specialist before aspirin.
   • A high-intensity statin and blood-pressure management follow per the specialist.

9. 9. Arrange specialist review within 24 hours and give driving advice

   Two items candidates frequently miss - both are graded.

   • Refer for specialist TIA assessment within 24 hours.
   • Advise the patient not to drive. For a single TIA, a private-car driver must not drive for at least one month and need not inform the DVLA if recovered; group 2 (bus/lorry) drivers have stricter rules and must notify the DVLA.
   • Advise them not to drive until reviewed and cleared.

10. 10. Safety-net and close

    Make the warning explicit.

    • Teach FAST: if face, arm or speech symptoms return and persist, call 999 immediately - that is a stroke.
    • Confirm the plan: aspirin now, clinic within 24 hours, no driving.
    • Invite questions, check understanding, thank them and close.

Common pitfalls

• Reassuring the patient that a fully resolved episode needs no action - a TIA is a warning of imminent stroke.
• Not starting aspirin 300 mg immediately.
• Not referring for specialist assessment within 24 hours.
• Forgetting driving advice entirely - it is a graded item.
• Not checking a capillary glucose (missing hypoglycaemia as a mimic).
• Failing to check the pulse or ECG for atrial fibrillation.
• Not safety-netting with FAST and a clear instruction to call 999 if symptoms recur and persist.
• Mislabelling an unresolved deficit as a TIA - if it persists, it is a stroke and needs the acute pathway.

Frequently asked questions