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TIA & STROKE PREVENTION
RAPID ACCESS REFERRAL

Fax this completed form and related records to desired location below LGH clinic only accepts TIA referrals Phone: 604-992-7141 See reverse for emergency contacts numbers
DATE OF REFERRAL:
REFERRED FROM:
Emergency Dept Inpatient Physician Office Specialist Name of Referring Physician:
REASON FOR REFERRAL:
PATIENT INFORMATION:
Last name of patient
Alternate contact person: (name and phone number)
DATE OF EVENT OR ONSET OF SYMPTOMS:
PRESENTING SYMPTOMS: (check all that apply)
Duration of symptoms:
Have symptoms resolved:
ANTITHROMBOTIC / ANTIPLATELET THERAPY:
RELEVANT HEALTH HISTORY:
PRELIMINARY DIAGNOSIS / PHYSICIAN NOTES: (Attach ED notes)
KEY INVESTIGATIONS: (attach results if available)
ABCD2 SCORING CHART
Age - 60 years or over
BP - history of hypertension
Clinical Features:
 Unilateral weakness (with or without speech disturbance) Duration:
Echocardiogram: if suspicion of cardiac cause  more than 10 minutes and less than 60 minutes Holter monitor: if suspect atrial fibrillation Diabetes
Score: (4 or more = High Risk)
INFORMATION FOR REFERRING PHYSICIANS
The following classifications and timing of diagnostic tests for TIA are recommended. Consider strokes and high risk TIAs as medical emergencies and perform investigations and treatment as soon as possible. These are suggestions that may not apply to all patients. Clinical judgment is required to determine urgency of referral and assessment. Key steps for investigating TIA:  Identify high risk patients based on clinical criteria
 When possible, conduct key investigations within the recommended timelines  Contact the neurologist on call to discuss high risk or complex cases (see contact numbers below)  Refer medium/low risk patients to a TIA clinic Emergency Contact numbers:
MINOR STROKE/TIA RISK ASSESSMENT
High Risk
 Symptoms within the previous 48 hours with any one of the following: • Motor deficit lasting more than 5 minutes • Speech deficit lasting more than 5 minutes  Acute persistent or fluctuating stroke symptoms  One positive investigation (acute infarct on CT/MRI; carotid artery stenosis)  Atrial fibrillation with TIA  Other factors based on presentation and clinical judgment Medium Risk
 Symptom onset between 48 hours and 7 days with any one of the following: • Motor deficit lasting more than 5 minutes • Speech deficit lasting more than 5 minutes • ABCD2 score of 4 or more  Symptom onset 7 or more days without the presence of high risk symptoms (speech deficit or motor deficit or ABCD2 score of 4 or more or atrial fibrillation with TIA) TIA Urgency Classification
Comments
CBC, Na+, K+, creatinine, INR & aPTT, fasting lipid profile Laboratory work
(CHO, LDL, HDL, TRIG), urinalysis, ECG, fasting glucose CT head scan
Investigation of choice for acute stroke and TIA Carotid imaging
Optimally within 24 hrs in a carotid territory TIA if the patient is a Additional investigations may be considered depending on case specifics:  MRI - If recommended by consultant
Holter monitor - Consider to detect paroxysmal AF
Echocardiogram - If a cardiac source of embolism is suspected, e.g. dysrhythmia, heart failure, LV dysfunction, post MI
If there are specific concerns or for high risk patients, consider sending to the emergency department or
contacting the neurologist on-call at your local hospital.

Source: http://www.plexia.ca/charlestai/TIACVA_referral.pdf

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