Transient Ischemic Attack (TIA)

Patient Presentation:
A.F., a 73 year old man arrives to the ER via ambulance from an assisted living facility.  Report from EMS is that patient began to have slurred speech and minimal left sided facial droop earlier in the morning.  Nursing facility was unable to determine the time symptoms began.  Initial blood pressure in the ER was 166/87, HR 54, temperature 98.9, respirations 18, and O2 sats 99% on room air.  Patient is slow to respond to questions, but is answering appropriately.  Patient has bilateral upper extremity strength.  Minimal right lower extremity weakness; patient reports “my left side is my strong side.”  Patient has a history of a TIA one week ago and a pontine infarct.  Fingerstick glucose is 173.  Electrolytes and CBC are within normal limits.  CT scan reveals old pontine infarct and minimal vessel change.  No new infarct or hemorrhage present.  Patient has a history of DM, hypertension, pontine infarct, TIA, and aortic stenosis.  While in the ER patient’s BP increases to 233/110 and HR 55.  Patient does not remember if he took his BP medication this morning.  BP remains elevated after 2 inches nitroglycerin paste is applied and 0.1 mg clonidine administered.  Hydralazine 10mg IV and 20 mg PO lisinopril is also administered and BP does eventually decrease to 170/98.  Patient denies pain or headache.  Minimal speech improvement occurs during his four hour stay in the ER before he is transferred to the SICU.

Differential Diagnosis:
Bells palsy, TIA/stroke, Brain tumor

Diagnosis:
Based upon clinical symptoms, patient’s uncontrolled hypertension, and risk factor of previous stroke, patient had a transient ischemic attack.

Treatment:
From SICU patient will be transferred to a telemetry unit where they will continue neurological checks and control the patient’s BP.  A referral for physical therapy or speech therapy will be made if patient continues to have speech deficits or right lower extremity weakness.

Outcome:
Typically symptoms of TIA do resolve completely.  For this patient the most crucial treatment will be aggressive control of his blood pressure.  Patient is at a greater risk for another stroke due to his previous stroke and hypertension.