What is the best course of action for an elderly patient with a history of Diabetes Mellitus (DM), hyperlipidemia, and Hypertension (HTN) presenting with left arm and leg tingling for 1 day, elevated liver enzymes, and stable vital signs?

Immediate Stroke Workup and Management

This patient requires urgent evaluation for acute ischemic stroke with immediate neuroimaging, vascular imaging, ECG, and stroke protocol activation—the elevated liver enzymes are a secondary concern that should not delay stroke evaluation. 1

Primary Clinical Concern: Acute Stroke vs TIA

The unilateral arm and leg tingling for 1 day in an elderly patient with multiple vascular risk factors (DM, HTN, hyperlipidemia) represents a high-risk neurological emergency requiring immediate stroke evaluation, regardless of the elevated transaminases. 1

Immediate Diagnostic Workup

Neuroimaging (Priority #1):

• MRI with diffusion-weighted imaging (DWI) should be completed within 24 hours of symptom onset to differentiate TIA from completed stroke and guide acute management 1
• CT head (already pending) will exclude hemorrhage but may miss early ischemic changes 2

Vascular Imaging (Priority #2):

• Noninvasive imaging of cervical vessels (carotid duplex or CTA) should be performed urgently to identify large vessel stenosis or occlusion 1
• Intracranial vessel imaging is reasonable to assess for intracranial stenosis 1

Cardiac Evaluation (Priority #3):

• ECG immediately to evaluate for atrial fibrillation or acute coronary syndrome 1
• Prolonged cardiac monitoring (telemetry) is reasonable given the cardioembolic risk 1
• Echocardiography if vascular etiology remains unclear 1

Laboratory Tests:

• Complete blood count, coagulation studies (PT/INR, PTT) 1
• Lipid panel (given hyperlipidemia history) 3, 4
• HbA1c to assess chronic glycemic control 2
• Repeat hepatic function panel with hepatitis B and C serologies (given AST 321, ALT 513) 5

Risk Stratification

This patient likely has an ABCD² score ≥3 (age ≥60 years, unilateral weakness, duration ≥60 minutes, diabetes present), indicating high risk of early stroke recurrence. 1

Hospitalization is indicated because the patient presents within 72 hours with high-risk features and requires rapid completion of diagnostic evaluation. 1

Blood Pressure Management Considerations

Critical caveat: Do NOT aggressively lower blood pressure in acute ischemic stroke. 2

• If BP >220/120 mmHg, cautious reduction of mean arterial pressure by 15% over 24 hours is safe using labetalol as first-line 2
• Avoid excessive BP lowering in the first 5-7 days post-ischemic stroke, as this is associated with adverse neurological outcomes 2
• Only lower BP aggressively if thrombolysis is planned (target <185/110 mmHg) or if concurrent acute coronary syndrome, heart failure, or aortic dissection is present 2

Elevated Liver Enzymes: Secondary Evaluation

The AST 321 and ALT 513 elevation is common in Type 2 diabetes (prevalence 16% for elevated ALT) and strongly associated with metabolic syndrome features. 5

Differential diagnosis for transaminitis:

• Non-alcoholic fatty liver disease (NAFLD)/steatohepatitis—most likely given DM, HTN, hyperlipidemia 5
• Viral hepatitis (B or C)—requires serologic testing 5
• Medication-induced hepatotoxicity (review all medications, especially statins) 3
• Acute hepatic ischemia (less likely with stable vitals, but consider if hypotension occurred)
• Cardiac hepatopathy (check troponin, BNP if acute coronary syndrome suspected)

Abdominal imaging (CT pending) will help evaluate:

• Hepatic steatosis
• Biliary obstruction (though transaminase pattern suggests hepatocellular rather than cholestatic injury)
• Hepatic masses or infiltrative disease

Glycemic Management During Acute Illness

Target glucose 140-180 mg/dL in non-critically ill hospitalized patients using scheduled subcutaneous insulin (basal-bolus regimen preferred over sliding scale). 2

• Avoid hypoglycemia, which increases cardiovascular risk and may worsen neurological outcomes 2
• Check HbA1c to assess chronic control (target <7% long-term, but avoid aggressive lowering acutely) 2

Cardiovascular Risk Factor Optimization (Post-Acute Phase)

Once stroke/TIA is confirmed and acute management completed:

Lipid management:

• Statin therapy is mandatory for secondary stroke prevention, targeting LDL <100 mg/dL (or <70 mg/dL for very high risk) 3, 4
• Diabetic dyslipidemia typically shows elevated triglycerides and low HDL despite normal LDL 3, 6

Blood pressure targets (chronic management):

• Target SBP 130 mmHg (range 130-139 mmHg if age >65 years), DBP <80 mmHg 2
• Use ACE inhibitor or ARB as preferred agents in diabetes with hypertension 2
• Thiazide diuretics or calcium channel blockers are appropriate alternatives or additions 2

Antiplatelet therapy:

• Aspirin 75-162 mg daily for secondary stroke prevention (dose depends on stroke protocol) 2

Critical Action Algorithm

1. Activate stroke protocol immediately (do not wait for CT results)
2. Complete MRI with DWI within 24 hours 1
3. Obtain carotid/vertebral imaging urgently 1
4. Continuous cardiac monitoring 1
5. Avoid aggressive BP lowering unless >220/120 mmHg 2
6. Maintain glucose 140-180 mg/dL with insulin 2
7. Hepatitis serologies and medication review for transaminitis 5
8. Neurology consultation for stroke management and secondary prevention

The elevated liver enzymes, while requiring evaluation, should not distract from or delay the urgent stroke workup, which takes absolute priority given the potential for devastating morbidity and mortality.