Stroke — FAST positive

PLAB 2 & PRES 3 · neurology · hard · 8 minutes

Candidate brief

You are an FY2 doctor/SHO in the Emergency Department. Mrs Helen Carter, 70, developed sudden difficulty speaking and right-sided weakness approximately 55 minutes ago. Her husband is present. Assess her, explain your concerns and initiate immediate management. Verbalise all examinations, investigations, treatments and escalation steps you would undertake.

What examiners look for

Recognises suspected acute stroke and treats it as time-critical. Calls the stroke team, starts ABCDE and establishes the exact last-known-well time before taking a long history. Checks facial, arm and leg weakness, speech/language, vision, neglect, sensation, coordination, headache, seizure and consciousness. Checks anticoagulants, bleeding risk, recent surgery/trauma, previous stroke, baseline function and vascular risks. Checks capillary glucose immediately to exclude hypoglycaemia. Requests observations, neurological examination/NIHSS, ECG, IV access and blood tests including FBC, renal profile, glucose and clotting. Keeps the patient nil by mouth until a validated swallow screen. Gives oxygen only if hypoxic and treats fever or abnormal glucose according to protocol. Does not routinely lower blood pressure unless required by the reperfusion pathway or another emergency. Arranges immediate non-contrast CT brain and CTA because reperfusion may be indicated. Does not give aspirin before haemorrhage is excluded. Recognises likely left anterior-circulation ischaemic stroke. Escalates urgently for thrombolysis because onset is within 4.5 hours and for thrombectomy assessment because CTA shows a left M1 occlusion. Does not delay referral for routine blood results. Explains that treatment depends on imaging, timing, contraindications and specialist assessment. Antithrombotic treatment follows imaging and the stroke-team protocol. Communicates in short sentences, allows time for aphasia and involves the husband with consent. Documents onset, deficits, medicines, baseline function and transfer. Major safety errors: missing glucose; delayed imaging/stroke-team activation; oral intake before swallow screening; aspirin before imaging; routine oxygen despite normal saturation; or failure to assess reperfusion.

Guideline references

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