Transient Hand Weakness and Clumsiness — Free SCA Practice Case
Woman with transient hand weakness and clumsiness
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Brenda Clark
Age
62 years
Consultation Type
VideoAge
62 (DOB: 14/09/1963)
Situation
Face-to-Face Consultation.
Reason for Encounter
"Patient states her right hand went completely weak and clumsy last night while reading in bed. She dropped her book. Her hand returned to normal after about 20 minutes, and she feels perfectly fine this morning."
Medical Records
- ●PMH: Hypertension, Osteoarthritis.
- ●Medications: Amlodipine 5mg OD.
- ●Allergies: NKDA.
Recent Notes
- ●Last BP check 6 months ago: 145/88. Smoking status: Ex-smoker (quit 10 years ago)
Patient Script
For the friend playing the patient role
Character Overview: You are Brenda, a 62-year-old retired teacher. You are sitting comfortably in the chair and appear completely healthy. Last night, while reading, your right hand suddenly felt like a heavy lump of lead. You couldn't grip your book, and it clattered to the floor. When you tried to pick it up, your fingers were numb and clumsy. The whole thing lasted about 20 minutes before normal feeling and strength crept back in. You are in total denial. You have convinced yourself you just "trapped a nerve" or "slept funny." You only booked the appointment because your daughter came over this morning, heard the story, and practically forced you to come. You are secretly quite shaken by how suddenly you lost control of your hand, as your mother had a massive stroke at age 70 that left her paralyzed. However, you will not volunteer the story about your mother's stroke or your hidden fear unless the doctor explicitly asks what you are worried about or gently challenges your "trapped nerve" theory.
Consultation Flow & Responses:
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The Opening
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If the doctor asks an open question: "Morning, Doctor. Honestly, I feel a bit silly taking up your time. My daughter insisted I come in. Last night I was reading in bed, and my right hand just went completely dead. I dropped my book and couldn't pick it up. It was fine 20 minutes later, so I've probably just trapped a nerve in my neck, haven't I?"
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Data Gathering (The Layers)
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Layer 1: The Event (Focal Neurology Screen):
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"It was completely out of the blue. One second I was holding the book, the next my hand was useless. It felt heavy and clumsy, and my fingers were tingling."
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"No, my face felt fine. I went to the mirror and smiled, and it wasn't drooping."
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"My speech was perfectly normal, I called out to my husband and he understood me fine."
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"My right leg felt a tiny bit heavy when I stood up, but nothing like the hand."
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Layer 2: Ruling Out Differentials (Migraine, Seizure, Hypoglycemia):
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"No headache at all. No flashing lights in my vision." (Rules out migraine with aura).
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"I didn't pass out or shake. I was wide awake the whole time."
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"My vision was fine, no blindness or double vision." (Rules out amaurosis fugax).
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Layer 3: Cardiovascular Risk & AF Screen:
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"I stopped smoking a decade ago. I take my blood pressure tablet every day."
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"I haven't noticed my heart racing or fluttering recently."
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Layer 4: ICE & The Core Revelation (The Hidden Fear) - ONLY REVEAL IF ASKED:
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If the doctor asks: "What are you worried this might be?" or "Why was your daughter so insistent you come?"
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Reaction (The Reveal): Your breezy demeanor drops, and you look anxious. "My daughter thinks it was a mini-stroke. I keep telling her it wasn't, but... my mum had a massive stroke when she was 70. She spent the last five years of her life in a nursing home, unable to speak or feed herself. That's my absolute worst nightmare. If this was a mini-stroke, does that mean the big one is coming?"
ICE — Ideas, Concerns, Expectations
(The patient does not volunteer these unprompted. These surface only when the candidate directly explores the patient's perspective.)
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Ideas: Brenda has convinced herself she trapped a nerve in her neck or slept in an awkward position. She clings to this explanation because the alternative is too frightening to consider. If pressed, she might say: "I reckon I just had my neck at a funny angle reading in bed. You can trap a nerve doing that, can't you?"
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Concerns: Her deepest fear — which she will not voice until directly asked — is that this was a mini-stroke and that a catastrophic stroke like her mother's is inevitable. Beyond the medical fear, she dreads the loss of independence: being unable to drive, becoming a burden, ending up in a care home. If this surfaces: "I just keep seeing my mum in that nursing home. She couldn't even hold a cup. I can't end up like that — I've got grandchildren to look after."
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Expectations: Brenda came primarily because her daughter forced her. What she wants is reassurance that it was nothing serious. However, if the doctor does identify a TIA, she wants to know exactly what happens next and what she can do to stop it happening again. "Honestly? I was hoping you'd tell me it was just a nerve and send me on my way. But if it's something more than that, I want to know what we do about it."
If Asked — Medical History and Medications
(Actor guidance — respond naturally only when the candidate specifically enquires about these items.)
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If asked about blood pressure / hypertension: "Yes, I've had high blood pressure for about five or six years now. I take my tablet every morning — amlodipine, I think it's called. To be honest, I'm not brilliant at getting it checked regularly. The nurse told me off last time because it had been six months."
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If asked about the last BP reading or whether it's well controlled: "The last time they checked it was about six months ago. I think the nurse said it was still a bit high — something like 145 over something? She said we might need to look at changing my tablet, but I never got round to booking a follow-up."
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If asked about osteoarthritis: "Oh, that's just my knees. They're stiff in the mornings and ache if I've been on my feet too long, but it doesn't really bother me day to day. I just take paracetamol now and then. It's got nothing to do with this hand business — that was completely different, it came on in a flash."
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If asked about amlodipine specifically or any side effects: "I take it every morning with my breakfast. Five milligrams, I think. I don't get any side effects from it, no swollen ankles or anything like that."
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If asked about allergies: "No, no allergies that I know of."
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If asked about smoking history: "I gave up ten years ago. I used to smoke about ten a day for maybe twenty years. Best thing I ever did, giving up. My husband still smokes, mind you, but I don't let him do it in the house."
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If asked about alcohol: "I'll have a glass of wine with dinner a few times a week. Nothing excessive. Maybe a bit more at weekends if we're out with friends."
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If asked about family history (beyond mother's stroke): "My mum had her stroke at 70 — that's the big one in the family. My dad had a heart attack in his late sixties but he recovered from that. No one's had diabetes or anything like that as far as I know."
Social History and Lifestyle Impact
(Actor guidance — this context can be volunteered naturally when discussing daily life or impact of the episode.)
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Occupation / daily life context: Brenda retired from teaching four years ago. She is active and independent — she drives herself everywhere, does the weekly shop, and picks her two grandchildren up from school three days a week while her daughter is at work. She and her husband also go walking with friends most weekends. She prides herself on being fit and capable for her age.
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Lifestyle impact of the condition: Although the episode resolved, it has quietly unsettled her more than she lets on. She can volunteer if the conversation turns to daily life: "The thing that really shook me was how suddenly it happened. One second I was fine, the next I couldn't hold a book. I've been gripping things all morning just to check my hand's still working properly. And I have to pick the grandchildren up from school tomorrow — what if it happens while I'm driving? I haven't told my daughter that bit because she'd never let me near the car." This concern about driving and the grandchildren provides a natural entry point for the candidate to discuss DVLA driving restrictions, which is a key negotiation element in this case.
If Asked — Associated Symptoms
(Actor guidance — respond only when the candidate specifically asks about these symptoms. All answers are consistent with a resolved TIA affecting the right upper limb with no residual deficit.)
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If asked about any neck pain or stiffness: "No, my neck feels perfectly fine. No pain, no stiffness — nothing like that."
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If asked about any recent trauma or injury to the hand, arm, or neck: "No, nothing at all. I hadn't done anything unusual — I was just sitting reading."
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If asked about chest pain: "No, no chest pain at all. I felt completely well apart from the hand."
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If asked about shortness of breath: "No, I wasn't breathless. I could breathe perfectly normally the whole time."
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If asked about any weakness or numbness today: "No, everything feels completely back to normal this morning. My hand is fine now — that's why I thought it was just a trapped nerve."
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If asked about any previous similar episodes: "No, nothing like this has ever happened before. This was the first time."
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If asked about any swallowing difficulty during the episode: "No, I could swallow fine. I had a cup of tea afterwards and it was perfectly normal."
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If asked about any dizziness or loss of balance: "No, I wasn't dizzy. When I got up to go to the bathroom I felt my right leg was a tiny bit heavy, like I said, but I didn't stumble or feel unsteady."
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If asked about any memory problems or confusion during the episode: "No, my mind was perfectly clear. I knew exactly what was happening — that's what made it so frightening, actually. I just couldn't make my hand work."
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If asked about any recent headaches in the days or weeks before: "No, I've not had any headaches recently."
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If asked about weight loss or fatigue: "No, I've been feeling well in myself. My energy's been fine."
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If asked about diabetes or blood sugar: "No, I've never been told I have diabetes. I don't know when I last had it checked, though."
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If asked about cholesterol: "I'm not sure, to be honest. I don't think anyone's checked it recently. I don't take any tablets for it."
Negotiation & Collaborative Management Plan
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If the Doctor agrees it was a trapped nerve or "funny turn":
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Reaction: "Oh, marvelous! I'll tell my daughter to stop fussing." (Note: Candidate critically fails for missing a TIA and sending a high-risk patient home without aspirin or referral).
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If the Doctor uses the word "Stroke" or "TIA" without checking what she knows:
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Reaction: Visibly frightened. "A stroke? But I'm fine today! Are you sure? What happens now?"
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If the Doctor offers Aspirin 300mg immediately:
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Reaction: "Aspirin? I have some of those in my handbag, I usually take them for headaches. I'll take one now."
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If the Doctor mentions the DVLA driving rules:
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Reaction: Frustrated. "Not drive? For how long? I have to pick my grandchildren up from school tomorrow! I feel perfectly fine, why on earth can't I drive?" (Testing the doctor's knowledge of the absolute 1-month TIA driving ban).
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising TIA: The Clinical Picture
- ●A TIA is a transient episode of neurological dysfunction caused by focal cerebral, spinal cord, or retinal ischaemia, without acute infarction. The critical distinction from a completed stroke is full resolution of all deficits, usually within minutes to a few hours.
- ●Presentation is identical to stroke in the acute phase: sudden-onset unilateral limb weakness, facial droop, dysphasia, or monocular visual loss (amaurosis fugax). The diagnosis is made retrospectively once complete resolution is confirmed.
- ●Isolated limb motor or sensory disturbance — such as sudden clumsy hand or arm heaviness — represents focal ischaemia in the contralateral hemisphere and must not be attributed to a compressive or peripheral cause without a thorough neurological screen first.
- ●The key temporal features that confirm TIA (rather than a structural, metabolic, or migrainous cause) are: sudden onset, complete resolution, absence of headache or aura, and no loss of consciousness or shaking.
Differential Diagnosis: Ruling Out the Mimics
- ●TIA must be distinguished from conditions that can produce transient focal neurology:
- ●Migraine with aura — typically preceded by visual aura (fortification spectra), associated headache, and slower 'march' of symptoms; no cardiovascular risk profile required.
- ●Focal (Jacksonian) seizure — may cause unilateral weakness or sensory disturbance; distinguish by asking about any jerking movements, post-ictal confusion, or loss of consciousness.
- ●Hypoglycaemia — can mimic focal neurology; ask about known diabetes, recent food intake, and sweating; resolves with glucose correction.
- ●Functional neurological disorder — typically in a younger patient, inconsistent on examination, no vascular risk profile; diagnosis of exclusion.
- ●Cervical radiculopathy or a 'trapped nerve' does not present with sudden-onset complete resolution within minutes — this distinction is clinically decisive.
Risk Stratification: ABCD2 Score
- ●The ABCD2 score quantifies short-term stroke risk following TIA and supports decisions around urgency of referral:
- ●Age ≥60 — 1 point
- ●BP ≥140/90 at presentation — 1 point
- ●Clinical features — unilateral weakness 2 points; speech disturbance without weakness 1 point
- ●Duration — ≥60 min 2 points; 10–59 min 1 point
- ●Diabetes — 1 point
- ●Brenda scores at least 4–5 (age, BP, unilateral limb weakness, duration 20 minutes), placing her in the high-risk category.
- ●Current NICE NG128 guidance mandates specialist TIA clinic assessment within 24 hours for all suspected TIAs, regardless of ABCD2 score. The older two-tier 24-hour vs. 7-day pathway based on ABCD2 is now obsolete — every suspected TIA is treated as requiring same-day or next-day specialist review.
Immediate Primary Care Management
- ●TIA is a time-critical emergency. The risk of completed, catastrophic stroke is highest in the first 48–72 hours — up to 10–15% within 7 days without treatment.
- ●Aspirin 300mg immediately: Give a single loading dose unless contraindicated (active peptic ulceration, known severe allergy, or the patient is already established on therapeutic anticoagulation — in which case do not add aspirin; refer urgently).
- ●Urgent TIA clinic referral within 24 hours: Arrange same-day or next-day specialist assessment. Do not refer routinely to neurology or general medicine outpatients — this pathway is too slow.
- ●Do not send the patient home without aspirin, a clear plan for urgent review, explicit red flag safety-netting, and the driving restriction advice.
The TIA Clinic Workup
Explain to the patient what specialist assessment will involve, so they understand the urgency and attend:
- ●MRI brain (diffusion-weighted imaging, DWI): Detects small areas of established infarction even where symptoms have fully resolved; if DWI positive, this reclassifies the event as a completed stroke.
- ●Carotid Doppler ultrasound: Screens for significant ipsilateral carotid stenosis. Stenosis of 50–99% is an indication for urgent carotid endarterectomy (within 2 weeks of the TIA) — the most effective intervention available for symptomatic carotid disease.
- ●ECG and cardiac monitoring: 12-lead ECG at minimum; prolonged ambulatory monitoring if the resting ECG does not identify a cause, to detect paroxysmal atrial fibrillation — the most important cardioembolic diagnosis to make, because it changes management from antiplatelet to anticoagulation.
- ●Bloods: Fasting lipid profile, HbA1c, FBC, glucose, renal profile, and coagulation screen.
Secondary Prevention: Antiplatelet Therapy
- ●Following the initial 300mg aspirin loading dose, long-term antiplatelet therapy will be established by the TIA clinic:
- ●Clopidogrel 75mg daily is the preferred NICE first-line antiplatelet agent post-TIA (NICE NG128).
- ●If clopidogrel is not tolerated, aspirin 75mg with modified-release dipyridamole 200mg twice daily is the alternative.
- ●Aspirin 300mg is not continued long-term — it is a loading dose only.
- ●If AF is identified on cardiac monitoring, antiplatelet therapy is replaced by anticoagulation (a DOAC such as apixaban or rivaroxaban) — anticoagulation is substantially more effective than antiplatelet therapy at preventing cardioembolic stroke.
Secondary Prevention: Statin Therapy
- ●High-intensity statin therapy should be initiated following TIA regardless of the patient's current cholesterol level. This is a guideline-directed recommendation (NICE NG128), not contingent on a lipid result.
- ●Atorvastatin 80mg nightly is the standard high-intensity choice.
- ●A baseline fasting lipid profile should still be obtained for monitoring purposes and to identify familial hypercholesterolaemia, but must not delay statin initiation.
Blood Pressure Optimisation
- ●The BP target post-TIA is <130/80 mmHg (NICE NG128) — more stringent than the standard hypertension target.
- ●Brenda's last recorded BP of 145/88 six months ago is above this target and was already flagged as inadequately controlled. This is a key modifiable risk factor requiring active management.
- ●Options include: increasing amlodipine to 10mg, or adding an ACE inhibitor or ARB (preferred agents for post-TIA BP reduction per NICE), or a thiazide-like diuretic (e.g., indapamide).
- ●BP optimisation is best coordinated through the TIA clinic at the same visit as antiplatelet and statin initiation, then followed up in primary care.
DVLA Driving Restrictions
- ●Group 1 licence (car/motorcycle): Must not drive for 1 calendar month following a TIA. This is a legal requirement, not optional. The patient does not need to notify the DVLA following a single uncomplicated TIA with full recovery, but must not drive during the restriction period.
- ●Group 2 licence (HGV/bus driver): Must not drive for 1 year and must notify the DVLA directly.
- ●Multiple TIAs in a short period: The restriction extends to 3 months for Group 1, and DVLA notification becomes mandatory.
- ●The candidate must raise this proactively, even when the patient has not asked. Omitting driving advice is a patient safety failure.
Safety Netting: When to Call 999
- ●If any of the following occur, the patient must call 999 immediately — do not wait for a GP appointment or call 111:
- ●Any new facial droop, arm or leg weakness, or speech difficulty — even if brief and resolving
- ●Sudden loss of vision in one or both eyes
- ●Sudden severe headache unlike any previous headache
- ●Loss of consciousness or collapse
- ●The urgency of calling 999 (rather than seeking GP advice) must be made explicit. A recurrent event in the window following TIA requires emergency thrombolysis assessment and must not be managed as a routine appointment.
- ●Planned follow-up: review by the GP within 1 week of TIA clinic attendance to review clinic findings, confirm secondary prevention medications are established, and check BP.