1. Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org

2. Medical Grand Rounds Clinical Vignette October 22, 2008 By: Yelena Kopyltsova, M.D.

3. Medicine-Surgery Conference Thursday, October 30th, at 5pm Surgery in Patients With Coronary Stents Speakers : Dr. William Slater Department of Cardiology Dr. Joseph Carter Department of Surgery Farber Auditorium (Bellevue Atrium) Food will be served

4. Chief Complaint 61 year-old man presents with right hand weakness, right facial numbness and dysarthria for 15 minutes

5. History of Present Illness The patient was in his usual state of good health until 2 days ago, when he noted garbled speech, blurry vision, right facial numbness, and right hand weakness that lasted around 8 minutes. Patient felt completely normal after and disregarded the symptoms. On the morning of presentation, he started to experience the same symptoms as two days earlier, but this time they persisted for 15 minutes. Although he was asymptomatic afterwards, his family urged him to come to the ED for evaluation.

6. Additional History PMH:PSH: Soc. Hx: Fam. Hx: Allergies:Meds:HypertensionHyperlipidemiaNone 15 pack-year tobacco history 1 glass of wine daily No illicit drug use Father deceased at 67 from MI Mother deceased from unknown causes NKDA Self-discontinued all meds 1 year ago

7. Physical Exam GENERAL: Caucasian man in no acute distress VS: BP 147/82 mmHg, HR 87 bpm, RR 14 /min, O2 saturation 98% on room air The remainder of the physical exam was normal

8. Laboratory Findings WBC: 6.3 Hemoglobin: 14 Platelet count: 258 Coagulation studies: within normal limits Lipids: HLD 35, LDL 156, Triglycerides 320 Glucose: 102 Electrolytes: within normal limits

9. Additional Data EKG: sinus rhythm with left ventricular hypertrophy, but no ST or T-wave changes CXR: no consolidations, effusions or pneumothorax

10. Normal Non-Contrast Head CT

11. Preliminary Diagnosis Transient ischemic attack

12. Hospital Course The patient was started on aspirin and admitted for observation and expedited workup He had a 2-D echo with bubble contrast and carotid ultrasound, both of which were normal. He had no dysrhythmias on his cardiac monitor. MRI of brain revealed mild to moderate microvascular disease

13. Further Work-up MRI with microvascular disease

14. Follow-up Patient was discharged home on a thiazide diuretic, statin, and aspirin His follow up is with neurology clinic He was counseled on benefits of smoking cessation At two months, the patient did not have any residual deficits and was compliant with medications

15. Final Diagnosis Transient ischemic attack due to small vessel disease