TIA Flashcards
You are the IMT 1 in the TIA Assessment Clinic. You have been asked to see Mr Adene, a 69-year-old gentleman who presented to A+E 24 hours earlier following a short episode of right hemiparesis and word-finding difficulty which had resolved on his admission to A+E. He was diagnosed as having a TIA and referred to your clinic for assessment. He has a background of hypertension, T2DM, and COPD.
You will be required to assess the patient and will be asked to discuss treatment options with the patient.
What questions are important to ask in the history when assessing this patient?
From the history it sounds likely that this patient has had a TIA, and he has several comorbidities which would also support this. My questions would be around understanding the event. I would initially start with open questions followed by more closed questioning to help me narrow my differential diagnosis.
Event
- When did it happen (time of day)
- What Sx occured: weakness (and distribution), difficulty with speech, slurring of words, change in sensation (and distribution), visual impairment, impaired mobility, balance issues
- How long did Sx last
- Any warning symptoms or events preceding the onset of Sx?
- Any change in conscious level?
- Any associated pain?
- Any previous similar episodes or diagnosis of stroke?
Then I would take a detailed PMHx - is his HTN and T2DM well controlled, how long on treatment for this
Social
- Smoking?
- Driving?
Detailed systems review to help with my differential diagnosis, maybe some Sx or issues missed
ICE
- Ask about their ideas, concerns and expectations
- Let them ask any Qs
What investigations would you order as part of your workup?
Bedside
- HR, BP, CRT
- 12-lead ECG
Bloods
- FBC, U&E, Bone profile
- LFTs, INR, Coagulation screen
- HbA1c, cholesterol
Imaging
- Carotid Doppler
- Echocardiography (AF)
- MRI head
Would d/w with consultant prior ordering these
Differential for TIA presentation?
I - Infections
- CNS abscess, encephalitis, sepsis
N - Neoplastic/Neurological
- Space-occupying lesions, tumors
- Post-ictal state (post-seizures)
- Migraine with Aura
- Demyelination (MS)
- Peripheral neuropathies (Bell’s)
V - Vascular
- Subdural / epidural haematoma
I - Inflammatory
- Vasculitis
T - Trauma
- Subdural/epidural haematoma
Labyrinthine disorders
- Vertigo, Meniere’s, labyrinthitis
Encephalopathies
- Hypertensive encephalopathy
- Wernicke’s encephalopathy
Others
- Acute confusional state
- Dementia
- Vascui
You confirm a TIA based on your Hx and Ix. What advice would you give to the patient and what treatments would you start in clinic?
Explain TIA
- A TIA is a warning sign of a potential stroke
- The mainstay of Rx is about prevention of a stroke
Lifestyle Changes: Encourage
- Physical activity - regular exercise
- Stopping smoking
- Low-salt, low-saturated fat diet
- Limit alcohol intake to <14 units per week
Treatment in clinic
- 21 days - Dual antiplatelet therapy (Aspirin 75mg OD + Clopidogrel 75 mg OD) after loading dose of Aspirin 300 mg OD
- If cardioembolic source identified, switch to anticoagulation
- High intensity statins - Atorvastatin 80 mg ON
- Cholesterol and LFTs to be checked 3 months later (and 12 months for LFTs)
- Target sBP < 130 mmHg (CIs: bilateral carotid stenosis)
Within two weeks
* Follow-up on carotid doppler > urgent endarterectomy if 70-99% stenosis
Your diagnosis reveal a diagnosis of atrial fibrillation. Would you start the patient on treatment?
Anticoagulation should be initiated in patients who p/w TIA who are found to have persistent or paroxysmal AF.
Treatment can be commenced as soon as imaging has confirmed no presence of haemorrhage.
The risk of bleeding can be assessed using the ORBIT bleeding risk tool
Please discuss initiating a direct oral anticoagulant with the patient (One of the interviewers will play the part of the patient)
Explain, Side effects, Monitoring, Interaction with aclohol
Direct oral anticoagulants (DOACs) are drugs which prevent harmful blood clots from forming in your blood vessels. They do this by slowing down the clotting process. They have a similar effect on thinning the blood as warfarin.
There are several side effects associated with a DOAC that you must be aware of. Seek medical attention if
* Prolonged nosebleed
* Bleeding from cuts
* Blood in stool/vomit/sputum/urine
* Spontaneous bruising
* Persistent headache
Seek emergency medical attention if you suffer any major trauma or head injury
DOACs do not need monitoring (like warfarin does), but kidney function needs to be checked prior to staring and reviewed if there is any change.
DOACs do not interact with alcohol, but drinking alcohol increases risk of falls and head injury when intoxicated
Happy to provide written information on the drug so that you can read it at your own pace prior to starting the medication so that you can make an informed choice
Not taking the medication increases the risk of further TIAs and strokes because of the atrial fibrillation - taking blood thinners reduces your risk by as much as two-thords
The patient asks you about driving. What would you tell them?
People with a TIA must not drive for one month
They do not need to inform the DVLA
If further TIA, must stop driving for 3 months AND inform the DVLA
You will now be given one minute to present this patient to your consultant as if it were the end of the clinic. Give an overview of your findings and tell us what the next steps of your management would be.
S: I have just assessed Mr Adene, a 69-year-old gentleman, who was referred to clinic following a transient episode of right hemiparesis and word finding difficulty.
B: He has a background of hypertension, type two diabetes, and COPD.
A: Based on my assessment I believe that the presentation is consistent with a transient Ischaemic Attack. I have arranged several investigations to help identify the source of the TIA and based on an ECG in clinic we have also confirmed a diagnosis of atrial fibrillation. I have spoken with Mr Adene about prevention of future stroke including lifestyle measures and have started him on high dose statin. Because of the atrial fibrillation I believe that Mr Adene would benefit from being on long term anticoagulation and have discussed this with the patient. I have spoken with him about driving and when he can return to this.
R: Mr Adene should be followed up in this clinic to check his response to the medications initiated today and to review the outcome of further investigations that I have arranged including his prolonged ECG monitoring and his MRI head so that a DOAC can be started safely. I have made sure to safety net and informed Mr Adene to present back to hospital should he have any recurrence of his presenting symptoms.
