Pre-visit stroke dossier — Denise Walker (64F)

Assembled overnight from 6 source documents · every line cites its source · view source documents · back to referral

Index event

TIA 07/27/2026 — transient right arm weakness and word-finding difficulty, ~40 min, resolved. Last known well 07/27 09:15. NIHSS 0. doc 2

Why they're here now

Recurrent fluctuating right-sided weakness x2 days (referral 08/20). Repeat CT 08/01 without acute change. doc 1doc 5

Imaging & events chronology

07/27/2026	Admitted	doc 2
07/27/2026	CT HEAD WITHOUT CONTRAST performed on patient Denise Walker with indication of transient right arm weakness, rule out hemorrhage.	doc 3
07/28/2026	CTA HEAD AND NECK performed on Denise Walker	doc 4
07/29/2026	Discharged	doc 2
07/30/2026	Wear period start	doc 6
08/01/2026	CT HEAD WITHOUT CONTRAST performed on 08/01/2026 for recurrent transient right-sided weakness. Findings: No acute hemorrhage. No new territorial infarct. Stable	doc 5
08/07/2026	Longest AF episode (4 hours 32 minutes, asymptomatic)	doc 6
08/13/2026	Wear period end	doc 6

Medication reconciliation

aspirin 81mgatorvastatin 40mg

lisinopril 10mg on referral med list (doc 1) but not on discharge list (doc 2) — confirm with patient

Mechanism workup — done vs missing

done	Vessel imaging CTA 07/28: right ICA ~40% stenosis (below surgical threshold)	doc 4
missing	Echocardiogram Ordered at discharge 07/29 — no completed echo report anywhere in packet	doc 2
done	Rhythm monitoring 14-day patch 07/30–08/13: paroxysmal AF, 2.1% burden, longest episode 4h32m	doc 6
done	Lipids / A1c LDL 118, A1c 6.1 (07/27 admission labs)	doc 2
done	Telemetry during admission 48h inpatient telemetry: sinus rhythm only (AF captured later on ambulatory monitor)	doc 2

Secondary-prevention gaps (rule-derived)

Atrial fibrillation documented on ambulatory monitor; patient is NOT anticoagulated

AF burden 2.1%, longest episode 4h32m (doc 6) vs "No anticoagulant" on current med list (doc 1). Anticoagulation decision is the central open question. doc 1doc 6

LDL 118 — above typical <70 post-TIA target on current atorvastatin 40mg

Consider intensification per treating physician judgment. doc 2

Echocardiogram ordered but never completed

Structural evaluation outstanding; ordered at discharge, absent from packet. doc 2

Open questions requiring physician judgment

Anticoagulation initiation given monitor-documented paroxysmal AF (burden 2.1%, longest 4h32m) in a post-TIA patient currently on antiplatelet only
Complete the outstanding echocardiogram before or at the visit
Management of 40% right ICA stenosis (below surgical threshold) alongside new AF finding
Statin intensity given LDL 118 post-TIA

Checklist prompts, not treatment recommendations. Timeline events were AI-extracted from de-identified text; workup status, gaps, and reconciliation are rule-derived and auditable. The treating physician owns every decision.