Transient Ischemic Attack (TIA)

Casebank History
1

Who you are:
You are a FY2 in A&E

Who the patient is:
Lydia Scar 67-year-old lady has been brought to the hospital by her husband due to weakness on one side of her body, facial dropping and slurred speech 3 hours ago. Symptoms lasted for 15 mins. General and neurological examination is normal. Her blood pressure is 150/90. Ct is normal.

Special note
A referral to TIA clinic has been arranged.

What you should do:
Talk to her husband, address his concerns and discuss management plan with him.

  • Take DESA in detail - don’t forget driving.

Build rapport

Doctor: I can see from my notes, that your wife had some weakness in her body.
Patient family member: Yes, doctor it was a horrible experience.
D: It must be worrying for you, do you know her condition now?
P: She is ok now.

BEFORE – DURING - AFTER
D: Any loss of consciousness?
P: No.
D: Any fits? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Did she have your meal as usual? (hypoglycaemia)
P: Yes.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did she feel like the room was spinning? (Meniere’s)
P: No.
D: Any trauma to her head?
P: No.
D: Any fever/flu-like symptoms? (Confusion)
P: No.
D: Did she by any chance bite her tongue or wet herself after the fall? Sorry, I have to ask that…
P: No.
D: Apart from this, is there anything else I should know?
P: No.
D: Any other concern?
P: I am worried if this was a stroke.
D: Is there a reason why you are worried about it being a stroke in particular?
P: I just read about it before.
D: I see where you’re coming from. Just a few more questions and I will address your concern.

FLAWS

P2 (PAST HX)
D: Has she ever had this problem before?
P: No.
D: Does she have any medical condition like DM, HTN, Cholesterol, or thyroid? P: No.

MAFTOSA
D: Is she taking any medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Tell me about her diet?
P: We eat healthy, home-cooked food.
D: What do you mean by that?
P: We eat plenty of fruit and vegetables and we love to cook.
D: Does she smoke?
P: No.
D: Does she drink alcohol?
P: No.
D: Any physical exercise?
P: Yes, we walk 30mins everyday
D: Do you think she may be stressed about anything?
P: No.

ICE
Examination:
→ Observations: measuring BP: 150/90
→ Chest: (examine heart).

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that your wife had arm weakness and slurred speech that lasted for 15 mins and when measured her blood pressure it was on the higher side. So I suspect she may have a condition called TIA (mini stroke). This is a momentary decrease in the blood supply to the brain and it’s either due to narrowing in the blood vessels in the neck or due to some rhythm problems in the heart and let me assure you it’s not stroke.
P: What is the chance of her getting stroke?
D: Unfortunately, the risk of her getting stroke is high.

Management

  1. Senior.
  2. Refer to TIA clinic
  3. Investigations:
    Blood
    • FBC – FBS → Clotting profile.
    • U & E.
    • ECG (heart tracing).
    • CT brain.
    • Doppler on blood vessels of the neck.
    • Don’t forget Thyroid in Hx and investigations as a cause AF.
  4. Symptomatic
    • Aspirin + BP medications.
  5. DESA
    • You already told me that you are leading a healthy lifestyle, so keep on doing that.
  6. Safety netting
    • If you do take her home, I’d like to inform you about the warning signs of stroke…
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