Station 44

Rizwan Khan

Age: 59 years old male

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s name:  Rizwan Khan 

Age: 59-year-old male

Past medical history

  • Hypertension
  • Hypercholesterolaemia 

Drug and Allergy History 

  • Amlodipine 10mg OD
  • Atorvastatin 20mg OD 

Recent notes/consultations

  • Nil

 

Patient booked an urgent appointment to discuss concerns

Patient's Story (Role player’s brief)

Patient’s Story 

You are Rizwan Khan, a 59-year-old man. You booked this urgent telephone appointment after experiencing some concerning strange symptoms yesterday evening. While watching television at home, you suddenly developed weakness in your right arm and leg and had difficulty speaking. These symptoms lasted for about an hour and then completely resolved.

Your wife was very worried and thought you might have had a stroke, but because the symptoms went away, you weren’t sure what to make of it and didn’t seek medical help immediately.

You are currently symptom-free and feeling well in yourself. You are fully compliant with your prescribed medications — Amlodipine and Atorvastatin.

Social History: You do not smoke, do not drink alcohol, and live with your wife. You work full-time as a taxi driver and are the main financial provider for your household, as your wife is a homemaker.

Ideas: You think the episode might have been a stroke or something serious.

Concerns: You are anxious because your best friend had similar symptoms before dying from a stroke in hospital. This has made you worry the same could happen to you.

Expectations: You want the doctor to explain what happened and tell you what needs to be done to prevent it from happening again.

If the doctor tells you that you should not drive, you will ask why — explaining that your work as a taxi driver is your only source of income and how important it is to continue supporting your family and paying your mortgage. 

Marking Scheme

Data Gathering and Diagnosis

  • Ask about time of onset and whether symptoms have resolved or still present 
  • Ask about unilateral weakness or sensory loss (e.g. numbness or tingling on one side of the body)
  • Ask about slurred speech or difficulty speaking
  • Ask about loss of balance or any vertigo
  • Ask about sudden, temporary loss of vision in one eye (suggestive of amaurosis fugax)
  • Ask about associated symptoms that may suggest atrial fibrillation — including chest pain, palpitations, and shortness of breath
  • Ask about compliance with current medications and whether blood pressure is well controlled
  • Ask about social history, including occupation (relevant to driving and safety advice)
  • Ask about family history of TIA or stroke
  • Give a working diagnosis of Transient Ischaemic Attack (TIA) based on resolved focal neurological symptoms

Example of explanation to patient​

Rizwan, thank you for calling in and sharing what happened, it’s very understandable to be concerned, especially after experiencing sudden weakness and difficulty speaking, even if it got better on its own. 

From what you’ve described, this sounds very much like a Transient Ischaemic Attack, or TIA, sometimes called a mini stroke.

It happens when there’s a temporary blockage of blood flow to part of the brain, which causes stroke-like symptoms that then go away. Even though you feel fine now, a TIA is a serious warning sign. It means there’s a higher risk of having a full stroke in the near future if we don’t act quickly. The good news is that there doesn’t seem to be any lasting damage. But it’s very important we don’t ignore this.

I’m going to refer you urgently to the TIA clinic, where a specialist will see you within 24 hours. They’ll run some tests, likely a CT scan of your head, ultrasound (Jelly scan) of your neck blood vessels, and blood tests, to assess the cause and help us prevent it from happening again. 

In the meantime, I’d like you to start taking aspirin 300 mg once daily immediately, if you’re not already on it, this helps thin the blood and reduce the risk of further clots. Keep taking it until the specialist tells you otherwise. 

Now, I know this part may be difficult, but I also have to advise you not to drive for now. I completely understand this affects your work as a taxi driver, and how much your family depends on you. But the reason for this is your safety and the safety of others. After a TIA, there’s a risk of another episode happening suddenly, which could be dangerous if you’re behind the wheel. 

If the specialist confirms that you have had a TIA, you will likely need to stop driving for 4 weeks. They will provide you with official guidance based on their assessment. In addition, I recommend that you contact your local county council, as they are responsible for taxi licensing and will be able to give you the most accurate advice regarding your ability to return to work. For now, please don’t drive, and try to arrange someone to take you to your appointment.

Regarding your finances, we can refer you to our social prescriber, if that’s okay with you. They can explore whether there are any benefits or financial support you may be entitled to while you’re unable to work.

Management

Management

  • Offer aspirin 300 mg immediately and advise the patient to continue taking this daily until they are seen by the specialist
  • Refer urgently to the TIA clinic for specialist assessment and investigations — this should take place within 24 hours of symptom onset
  • Advise the patient not to drive and to arrange for someone to take them to the hospital or clinic
  • Inform the patient that driving is not allowed until they have been assessed by a specialist and declared fit to drive
  • Explain that most taxi drivers hold a Group 1 licence, and according to DVLA guidance, they must not drive for at least 4 weeks following a TIA (If TIA is confirmed by specialist) 
  • Advise that taxi licensing is managed by the local council, and the patient should contact their local licensing authority for further guidance about returning to professional driving
  • Explain what to expect in secondary care — likely investigations include a CT head scan, carotid doppler (neck ‘jelly scan’), ECG, and blood tests
  • Arrange follow-up consultation to review findings and outcome of the TIA clinic assessment
  • Safety net — advise the patient to call 999 immediately if symptoms return, such as sudden weakness, speech difficulty, or loss of vision

Learning point from this station: ​

This station highlights the importance of recognising and urgently managing a Transient Ischaemic Attack (TIA) in primary care. A TIA is a medical emergency and a strong warning sign for future stroke, even when symptoms resolve quickly.

While typical symptoms may include sudden weakness, speech difficulty, or facial droop, it’s important to know that TIA can also present more subtly — for example, with:

  • Amaurosis fugax (transient loss or blurring of vision in one eye),
  • Sudden tingling or numbness in one part of the body that resolves
  • Or other transient neurological symptoms that fully resolve.

Referral Timing for Suspected TIA (as per NICE):

If suspected TIA occurred within the last 7 days: Refer urgently for specialist assessment and investigation — the patient should be seen within 24 hours of symptom onset.

If suspected TIA occurred more than 7 days ago: Refer for specialist assessment as soon as possible, to be seen within 7 days.

  • NOTE: Sometimes it can be confusing when NICE says patients with suspected TIA that occurs within 7 daysshould be “seen within 24 hours of symptom onset.” This means that, ideally, the specialist assessment should happen within 24 hours from when the symptoms started — not 24 hours from when the patient contacts the GP or healthcare professional.
  • However, if the patient presents after the 24-hour window but within 7 days of the event, you should still make an urgent referral (same day) to the TIA clinic. The aim is to ensure prompt investigation and stroke prevention, even if the ideal 24-hour window has already passed. 

If the patient has a bleeding disorder or is on anticoagulation, arrange an urgent CT head same day (usually via emergency department or acute medical unit) to exclude haemorrhage.

DVLA guidance following a TIA is crucial. Individuals holding a Group 1 licence (e.g. car and motorcycle drivers) are advised not to drive for at least 1 month (4 weeks) after a TIA. For those with a Group 2 licence (e.g. lorry and bus drivers), driving must cease for a minimum of 1 year, and resumption is only permitted once a doctor confirms it is safe to do so.

Most taxi drivers hold a Group 1 licence, but it’s important to note that taxi licensing is regulated by the local county council. Therefore, the patient should be advised to seek specific guidance from their local licensing authority regarding when they may safely and legally return to professional driving. 

Further reading