Patient: An 80-year-old woman with a background of Alzheimer’s disease is brought in by her daughter.
The daughter reports that earlier in the day, her mother suddenly developed slurred speech and weakness in her right hand, lasting about 20 minutes before resolving completely. She also seemed confused during the episode, but now has returned to baseline.
No chest pain, breathlessness, or palpitations. No history of head trauma or fever. Her daughter says she has been compliant with medications but sometimes forgets meals.
Pulse: 88 bpm, regular
Blood Pressure: 148/86 mmHg
Respiratory Rate: 16/min
Oxygen Saturation: 98% on room air
Temperature: 36.8°C
Allergies: None known
Past Medical History: Alzheimer’s disease (diagnosed 5 years ago), hypertension, hypercholesterolaemia.
Medication History:
Donepezil 10 mg OD
Amlodipine 5 mg OD
Atorvastatin 20 mg OD
Social History: Lives with daughter, no smoking, no alcohol.
Question: What is your next step in managing this patient?
Incorrect. Transient ischaemic attacks (TIAs) are medical emergencies requiring urgent assessment to prevent progression to stroke. Delaying referral could result in a catastrophic outcome.
Outcome: Later that evening, the patient develops left-sided weakness and slurred speech, consistent with a stroke. She is rushed to the hospital, but the delay in intervention worsens her prognosis.
Correct! Referral to a TIA clinic is critical for same-day assessment, risk stratification, and initiation of secondary prevention measures.
TIAs are high-risk events, especially in patients with vascular risk factors like hypertension and hypercholesterolaemia.
Outcome: You refer the patient to the same-day TIA clinic. You provide safety netting advice, instructing the daughter to call emergency services if symptoms recur.
Incorrect. While neuroimaging is essential, immediate CT in primary care is not routinely indicated. As a PA, you cannot directly request imaging; this is arranged after specialist review.
Outcome: You escalate the case to your supervising clinician, who advises referring the patient urgently to the TIA clinic.
Near miss. While aspirin is correct for acute management, simply waiting a week for follow-up is unsafe. Urgent TIA clinic referral is still required.
Scenario: Secondary Care
You are a Physician Associate working in the TIA clinic. An 80-year-old woman with Alzheimer’s is referred after a suspected TIA. She presents with her daughter, describing a brief episode of slurred speech and right-hand weakness that resolved earlier. The GP initiated aspirin and sent her urgently here.
The patient is alert but slightly confused (her baseline). She denies current neurological symptoms.
Vital Signs:
Pulse: 84 bpm, regular
Blood Pressure: 150/88 mmHg
Respiratory Rate: 16/min
Oxygen Saturation: 98% on room air
Temperature: 36.7°C
ECG: Normal sinus rhythm, no AF Bloods: Elevated total cholesterol (6.5 mmol/L), HbA1c 45 mmol/mol (normal) Imaging: CT brain: no acute abnormalities
Carotid Doppler: 50–69% stenosis of right internal carotid artery
Question: What is your next step in managing this patient?
Incorrect. Carotid stenosis >50% in a symptomatic patient is a high-risk feature requiring urgent intervention. Discharging without escalation is inappropriate.
Correct! Carotid endarterectomy within two weeks significantly reduces stroke risk in patients with >50% stenosis and recent TIA or stroke symptoms.
Action: You discuss the findings with your supervising clinician and arrange for an urgent carotid endarterectomy.
Near miss. Although clopidogrel is reasonable for secondary prevention, delaying definitive intervention is dangerous with significant carotid stenosis.
Incorrect. The TIA diagnosis is well-established based on clinical history and Doppler findings. The priority is to address the carotid stenosis, not further imaging.
Case Conclusion
The patient undergoes a successful carotid endarterectomy, reducing her stroke risk.
She is discharged with optimized medications and clear safety-net advice.
Early recognition and intervention were key to preventing further complications.
