Nora Lippmann was a new patient. She was only 52, but she had a large dossier of old medical records from multiple contacts with many kinds of medical providers.
Our first visit was fairly brief, accelerated in my schedule because she was running out of some of her medications. She had moved to this area after an episode of domestic violence downstate.
Her prescription needs were fairly straightforward, but as she had already run out of her blood pressure medication, it was hard to know if that was the right one at the right dose.
She mentioned she had been to the emergency room a couple of days earlier. I pulled up the report from Maine Health InfoNet. She had gone there for tingling of the left side of her face. It was all better by the time she was evaluated. Her neurological exam was normal and she was discharged without a diagnosis.
Our visit was a little scattered, but I did a quick physical exam. She had a very loud bruit in her right carotid artery. I felt a chill in my spine. She had had a transient ischemic attack, and that was one of the loudest carotid bruits I’ve ever heard. What if she had a critical carotid artery stenosis?
I now know she appears to have just that. Her ultrasound showed a “greater than 70% to near total occlusion” of her right Internal carotid artery. She needs a CT angiogram of her carotid arteries ASAP.
I routinely listen to carotid arteries, although the current US Public Health Service Taskforce on Prevention doesn’t recommend it. So maybe it is no surprise nobody had listened for bruits and caught this whopper before I did, but when somebody has a possible TIA, it should be standard operating procedure to listen for bruits.
More than a decade ago, I confessed to not picking up a critical carotid artery stenosis until the third visit of a new patient without symptoms. It all ended happily, but I still remember how humbled I was when I realized I almost missed it.
A Country Doctor Writes: 
The first asymptomatic carotid bruit I referred to Pinehurst had an endarterectomy and died. The first abdominal aortic aneurysm I felt and referred lived a long time after it surely would have fatally ruptured. Ours is no profession for ‘second guessers’ but surely requires continuing learning.
My own 95% stenosis in the LAD dilated and stented beautifully; sure would have killed me the next time Nancy was close. That was 2 years ago and she is wonderfully close now every night.
Great pick-up. True the USPTF does not currently recommend screening for carotid stenosis in asymptomatic patients. However, I still perform the test during exams, particularly in patients with a risk of atherosclerosis. If positive for a bruit and the US / angiogram suggest non-surgical plaque disease, I can consider secondary prevention strategies. Besides, it is a quick exam and provides the physical touch that is beneficial for patients