TIA

Question

65-year-old gentleman with a past medical history of hypertension that is poorly controlled and diet control type two diabetes mellitus has come into the emergency department after complaining of transient monocular loss of vision for 20 minutes. How would you assess this patient?

Answer

I would start off by first getting a focused history from the patient regarding the onset of symptoms. Specifically, I would be looking for the rapidity of onset of symptoms (whether it was hyper-acute in nature or if it was progressive). I would also ask for other focal neurological symptoms at the time of the event such as concurrent facial weakness, arm or leg weakness, speech disturbance, and sensory loss. I would review his past medical history, specifically looking at the blood pressure and that diabetes control and assess the vascular factors. After that, I would do a focused A to E assessment.

• Airway: I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct I would be really worried and seek the help of the critical care team after my assessment.
• Breathing: I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing I’ll start the patient on supplemental oxygen therapy. I would also get an ABG for this patient if there was evidence of hypoxia to see what the pH, pO2, pCO2 and HCO3 and lactate.
• Circulation: I would look at the observations specifically the BP, heart rate and CRT. If there is evidence of hypotension or tachycardia I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotensive despite the first fluid challenge I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient.
• Disability: I would check the patient’s blood glucose, temperature and do a focused neurological assessment that includes GCS. Specifically if the GCS is less than 8 or if there are focal neurological deficits I would be concerned and investigate this further. Given that he had acute loss of vision I would also do a fundoscopic assessment.

Question

At this point, interrupt the candidate and mention that the patient had no other focal symptoms. He had an isolated right-sided monocular loss of vision that lasted 20 minutes. Neurological examination, including fundoscopy, is completely normal. His blood pressure is poorly controlled, and he hasn’t checked his blood glucose in a long time. How would you manage this patient further?

Answer

This gentleman’s symptoms and signs are in keeping with a possible TIA. I would ensure that his blood pressure medications are reviewed and optimized and that he had his mini-stroke blood work done, which would include CRP, lipid profile, renal function, HbA1c, liver function, coagulation screen, and full blood count. I would refer him urgently to the TIA clinic and ensure that he started on antiplatelet therapy after looking at drug allergies. I would also start him on secondary preventative methods such as lipid management with statins. I would also review his ECG that was done earlier to look for any evidence of atrial fibrillation.

I will check his driving status and inform him about the DVLA guidelines (not to drive for four weeks after onset of symptoms). I would also safety-net him as to when he needs to seek help, i.e., if he has any acute focal neurological deficit, he will need to come to the hospital.