An 81-year-old man comes to the physician with an episode of right arm weakness and difficulty finding words. The episode occurred the night before and lasted 90 minutes, followed by slow resolution of symptoms. He had no loss of consciousness. He has never had similar symptoms and otherwise feels fine. The patient's medical history includes hypertension and type 2 diabetes mellitus. His medications include lisinopril, metformin, and glipizide. His last hemoglobin A1c was 7.6%. He quit smoking 5 years ago.
The patient's blood pressure is 130/80 mm Hg and pulse is 88/min. His body mass index is 30 kg/m². Cardiac examination shows no murmurs. No carotid bruits are heard and lungs are clear to auscultation. Peripheral pulses are full and symmetric. Neurologic examination, including visual field testing, is within normal limits. Fingerstick glucose level is 176 mg/dL. Electrocardiogram shows normal sinus rhythm.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_9887_3c87_853d_db82de49f18e_MD0002_00 This patient's presentation suggests transient ischemic attack (TIA), defined as a transient episode of neurologic impairment (of central nervous system origin) without acute infarction. Patients with TIA or minor stroke without residual deficits require immediate evaluation due to higher risk of recurrent stroke. The ABCD² (Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes) score is a prognostic tool designed to predict the risk of ischemic stroke in the first 2 days after TIA. Although some studies have shown inconsistent results, the ABCD² score is frequently used to identify patients requiring immediate evaluation by specialists. The National Stroke Association recommends hospitalization for all patients with a first TIA within the last 24-48 hours and the following conditions: Duration of symptoms > 1 hour Symptomatic internal carotid artery stenosis > 50% Multiple recurrent TIAs Atrial fibrillation or other known cardiac source of embolus Hypercoagulable state High risk of stroke after TIA as determined by the ABCD² score Duration of symptoms > 1 hour Symptomatic internal carotid artery stenosis > 50% Multiple recurrent TIAs Atrial fibrillation or other known cardiac source of embolus Hypercoagulable state High risk of stroke after TIA as determined by the ABCD² score This patient's ABCD² score is 6, demonstrating a high 2-day stroke risk of 8%. He should be hospitalized for appropriate expedited testing and stroke prevention treatment to reduce his risk of stroke within the next 48 hours. (Choice B) Initial TIA workup should include carotid imaging (ultrasonography, computed tomography [CT] or magnetic resonance [MR] angiography), brain imaging (with CT or MR imaging), and electrocardiogram. Patients with negative initial studies should undergo echocardiogram to determine the etiology of TIA or ischemic stroke. Echocardiogram is also indicated for patients with suspected endocarditis or who are candidates for anticoagulation (eg, atrial fibrillation). (Choice C) The American Diabetic Association recommends hemoglobin A1c < 8.0% for older patients to minimize hypoglycemia, which is more common in the elderly. This patient's hemoglobin A1c is at the goal and does not require insulin. (Choices D and E) This patient's risk factors and ABCD² score require immediate hospitalization for further investigation instead of outpatient evaluation. Preventive therapy (eg, aspirin, statin) is recommended for patients such as this with recent (< 2 weeks) TIA. < Educational objective: Patients with recent (within 24-48 hours) transient ischemic attack (TIA) and risk factors (eg, multiple recurrent TIAs, atrial fibrillation, symptom duration > 1 hour, symptomatic internal carotid artery stenosis > 50%, hypercoagulable disorders, or high ABCD² score) have higher risk of stroke within the next 48 hours. They should be hospitalized for further investigation and prevention. __________ References: National Stroke Association guidelines for the management of transient ischemic attacks. (http://www.ncbi.nlm.nih.gov/pubmed/16912978) Validation and refinement of scores to predict very early stroke risk after transient ischemic attack. (http://www.ncbi.nlm.nih.gov/pubmed/17258668) Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. (http://www.ncbi.nlm.nih.gov/pubmed/19423857)

An 81-Year-Old Man Comes to the Physician with an Episode