Running Head: TIA CASE STUDY
1
TIA Case Study
Kevin M. Ryan
Old Dominion University
NURS 639
Professor Sharp
TIA CASE STUDY
TIA Case Study
The case study for this paper is based on patient that presents as a possible TIA
(transient ischemic attack). The goals of the case study include, but are not limited to,
understanding what history to collect, what systems to examine or assess, ,and what the most
likely diagnosis and differential diagnosis will exist. The assignment requires the inclusion of
what consults, work ups, and any supporting clinical practice guidelines used. It is also
important to state any needed immunizations related to the patients hospital stay, and those
that may be needed through the PCP (primary care physician) after the stay. The case study
should conclude with suggested teaching and patient education, which is so important with
each patient and family interaction.
Patient Presentation
The patient presents as a 78-year-old male with a primary concern stated as a sudden
onset, right-sided weakness that occurred over the weekend. The patient is accompanied by his
wife and daughter. The patient and family report that the sudden onset right-sided weakness
completely resolved itself in about two hours. They further state that no medical treatment was
sought at the time because the weakness resolved itself in about two hours. The patient is here
today at his daughter's urging.
The patient and family report that he had a diagnosis for mild hypertension in 2005.
They state that he had been advised that he had hyperlipidemia “a few years back”. The
patient refused to take any medication or change his lifestyle at that time. He and the family
also reports that he has not been back to see his PCP since, and that he did take
hydrochlorothiazide 50 mg daily “for a year or so in 2005-2006”, does not take it any longer.
TIA CASE STUDY
3
They report the patient occasionally takes OTC (over the counter) acetaminophen and Goody’s
headache powder. No other medications are reported at this time. The patient and family
report that he is a smoker, with about a 64 pack year history. The patient has not received any
immunizations for more than a decade, and has not been to see his PCP for some years now.
Additional History of Present Illness
It is important to start with assessing the patient’s vital signs; current temperature,
pulse, respirations, and blood pressure. The patient’s history related to alcohol use, diabetes,
obesity, and sedentary lifestyle should be reviewed. The patient should be assessed for bilateral
strength of both upper and lower extremities. A visual assessment of the patient's face
bilaterally as well as a neuromuscular assessment should be done. It is important to gain a
detailed account of the event with inaccurate time of onset, as well as resolution. ABCD and/or
the ABCD2 assessment and scoring are known to be good indicators (Johnson et al., 2006).
The patient and his families past medical history should be discussed to see if any family
members had past TIAs or strokes, which is a known risk factor. Other risk factors include;
hypertension, cardiac disease, smoking, diabetes, hypercholesterolemia, and atrial fibrillation
(Johnson et al., 2006). The patients age, disease history, and life style to support a possible
diagnosis of TIA.
Systems and Physical Examine
A focused physical examination should be completed. The assessment should include his
cardiovascular system, HEENT (head, eyes, ears, nose, and throat), endocrine system, and his
neuromuscular systems. The cardiovascular system should be assessed specifically for carotid
stenosis, atrial fibrillation, and any prior history of hyperlipidemia and hypertension (Nanda,
TIA CASE STUDY
4
2011). The patient's blood sugar should be tested and reviewed for signs of diabetes. A
complete HEENT (head, eyes, ears, nose, and throat) examination should be done (Nanda,
2011), with focus on any loss of vision, any tinnitus, any hearing loss, and/or any other
neurological deficits bilaterally should be evaluated. The patient should be assessed for
muscular strength and ROM (range of motion) bilaterally, and an assessment of all cranial
nerves should be completed.
Differential Diagnosis
The initial diagnosis for the patient is TIA (transient ischemic attack). A few of the
differential diagnosis that exist include: neoplasm of the brain, migraine, hypoglycemia, and
subarachnoid hemorrhage. Assessment findings with imagery and lab results would enable the
practitioner to rule out most of these as differential diagnosis.
A brain scan or imagery using CT (computer tomography) without contrast or a DWI
(diffusion-weighted magnetic resonance imaging) would enable the practitioner to rule out a
neoplasm of the brain and a subarachnoid hemorrhage (Domino, 2009). In most cases the
imagery would provide evidence of a neoplasm or any subarachnoid hemorrhage. For the
purposes of this case study we will assume the test results were negative for these findings.
Assessment findings and detailed observations of the event can be used to rule out
migraine as a possible diagnosis. A TIA event generally takes place suddenly, as compared to a
migraine which often has a more gradual onset. A migraine does not usually lead to weakness
on one side of the body as is often the case with the TIA. Based on reports from the patient and
his family a “sudden onset, right-sided weakness” took place that resolved of its own accord in
about two hours, enabling a possible migraine to be ruled out in this case (Domino, 2009).
TIA CASE STUDY
5
Hypoglycemia can have signs and symptoms that are similar to those of the TIA. Some
examples include blurred vision, headache, and confusion. Blood sugar testing would help rule
out this possible diagnosis. Hypoglycemia generally does not lead to left or right sided
weakness. For the purposes of this case study testing for hypoglycemia is negative at this time,
and hypoglycemia is ruled out as a possible diagnosis (Domino, 2009).
Diagnostic Tests and Plan
Assessment tools for symptoms of stroke and transient ischemia attack include FAST (face, arm,
speech test), ROSIER (recognition of stroke in the emergency room), and the ABCD2 assessment
for people suspected of having a TIA and for risk of subsequent stroke. A brain scan or imagery
using CT (computer tomography) without contrast in the acute phase, or a DWI (diffusionweighted magnetic resonance imaging) should be ordered if time permits. Carotid imaging is
suggested for proper evaluation, diagnosis, and risk assessment (“Guidelines,” 2015). It is now
believed that diffusion-weighted magnetic resonance imaging (DWI) is considerable superior
compared with CT scanning. (Panagos, 2012) It is also a good idea to have Doppler carotid
imaging and an electrocardiogram done to detect possible restriction and/or arrhythmias.
Blood tests should include a complete blood cell count, measurement of glucose and
creatinine levels, and electrolytes studied. Test for INR and PTT, as well as cardiac enzymes can
be done as well. These tests will enable the practitioner to rule out problems like anemia,
leukocytosis, polycythemia, and diabetes (Johnson et al., 2006).
The plan of care should include a referral to the hospital for testing as noted. As consult
from a neurologist, a cardiologist, and a radiologist should be requested (Johnson et al., 2006).
A vascular surgeon could also be needed. If a TIA is confirmed, the first line medications could
TIA CASE STUDY
6
include aspirin 81-325 mg once daily, or Clopidogrel (Plavix) 75-100 mg three times daily.
Heparin could be used as a bridge to long term Warfarin which would be adjusted based on INR
if atrial fibrillation and/or cardioembolic stoke were diagnosed.
Education related to all testing, the results of the test, and any diagnosis should be done
as the process moves forward. The suspected causes, treatments, and prognosis should be
discussed with the patient and the family in terms they can understand. The signs and
symptoms of a TIA, a stroke, and what should be done if observed should be included in the
care plan.
Immunizations Schedule
The patient should receive an influenza immunization upon admission into the hospital.
Based on the information provided, the patient should follow up with his PCP to discuss
immunizations for the pneumococcal PCV13/PPSV23, shingles zoster, and varicella if the PCP
has no records of these immunizations. The PCP may also want to give a 10 year Tdap booster if
no record of this exists in the prior 10 years (“ACIP,” 2015).
Additional Teaching and Health Concerns
Teaching will be in important for this patient, as prior intervention by healthcare
professionals has been ineffective. It will be important to involve the patient, his wife, and his
daughter in developing his plan of care going forward. It is important to try and speak to the
patient and his family at their level. Explaining the impacts of hyperlipidemia, hypertension, and
any other co-morbidity is a good starting point. Discussing the value of lifestyle changes such as
smoking cessation, diet and exercise, as well as adherence to medication regimens with the
patient and his family is important. Listening to their concerns and needs for assistance will
TIA CASE STUDY
7
help the practitioner to better understand barriers to compliance. Planning to overcome these
barriers may involve outside resources and referrals.
Follow-up Screening
The patient should follow-up with his PCP within a week of being discharged from the
hospital. The patient should be instructed to follow-up with his cardiologist, and/or neurologist
at least every three months during the initial year following his hospital stay. If no future TIA
events take place, annual follow should then be recommended. Depending on the diagnosis,
follow-up assessment or testing should include blood pressure monitoring, ABCD2 scoring, an
electrocardiogram, an assessment of the patient's hyperlipidemia, and the review of all of his
medications.
References
Domino, Frank J. The 5-minute Clinical Consult. 17th ed. Philadelphia: Lippincott Williams &
Wilkins, 2009. Print
Johnson, S. C., Albers, G.W., Gorelick, P. B. Cumbler, E., Klingman, J., Ross, M. A., … Vaince,
U. (2011, May). National Stroke association recommendations for systems of care for
TIA CASE STUDY
transient ischemic attack. Annals of Neurology, 69, 872-877.
http://dx.doi.org/10.1002/ana.22332
Nanda, A. (2011). Transient ischemic attack. Retrieved February 24, 2015, from
http://emedicine.medscape.com/article/1910519-overview
Panagos, P. D. (2012). Transient ischemic attack (TIA): The initial diagnostic and therapeutic
dilemma. The American Journal of Emergency Medicine, 30(5), 794-9.
doi:http://dx.doi.org/10.1016/j.ajem.2011.03.004
Stroke. Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA).
(2015). Retrieved February 22, 2015, from
www.guideline.gov/popups/printView.aspx?id=14328
Vaccine recommendations of the acip. (2015). Retrieved April 2, 2015, from
http://www.cdc.gov/vaccines/hcp/acip-recs/index.html
8
TIA CASE STUDY
9
The Honor Pledge:
I, Kevin M Ryan, pledge to support the Honor System of Old Dominion University. I will
refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am
aware that as a member of the academic community it is my responsibility to turn in all
suspected violators of the Honor Code. I will report to a hearing if summoned.
Kevin Michael Ryan
Kevin Michael Ryan
Thursday, April 2, 2015
TIA CASE STUDY
10
Rubric for Case Study
Section
History:
Correct identification of additional HPI components (10 pts)
Additional Physical Exam:
Discussion of systems to examine and pertinent negatives for
each (10 pts)
Differential Diagnoses
What is on the list of possible diagnoses for this patient?
What are the symptoms that lead you to include or exclude
each of these potential diagnoses? Must include sources.
(15 pts)
Diagnostic Tests and Plan (30 pts)
Immunization Schedule (10 pts)
Additional Health Teaching/Concerns (15 pts)
APA format for Citations, Reference Page (10 pts)
Instructor comments