01

LEARNIN
G
OBJECTIV
ES
Learning Objectives

GENERAL OBJECTIVE:
To discuss a case of a 51 year old, female, presenting with right sided body
weakness.

SPECIFIC OBJECTIVES:
1. To formulate an appropriate diagnosis based on the patient’s history and
physical examination.
2. To effectuate a therapeutic plan based on the patient’s clinical
manifestations and current health condition.
3. To present a concept map associating the patient’s clinical signs and
symptoms with the pathophysiology of the disease.
 02

CASE PROTOCOL
 GENERAL DATA
51 year old/ female Dec. 19, 1969

Married, Filipino Manila

Patient: D.
Roman Catholic
First consult in our
institution last March
4, 2021
CHIEF COMPLAINT

Right Sided Body Weakness

 HISTORY OF PRESENT
ILLNESS
(+) Blood pressure
Few Hours 186/94 mmHg
PTA

(+) Right sided body

weakness Admitted
(+) Associated with slurring
of speech and facial
asymmetry

(-) Medication taken

 PAST MEDICAL HISTORY

(-) Hypertensive (+) S/P Caesarian

(-) Diabetic section due to
(-) Asthmatic Placenta Previa,
(-) History of pulmonary 2000 and
tuberculosis S/P Bilateral Tubal
(-) History of previous Ligation, 2000
CVD
(-) History of surgery
 FAMILY HISTORY

Paternal Lung Cancer

No other heredofamilial diseases

Maternal Hypertension
PERSONAL AND SOCIAL HISTORY

Separated (-) Smoker and alcohol

Lives with her daughters, beverage drinker
2 grandchildren and son- (-) History of illicit drug
in-law use

Prefers to eat vegetables

but consumes fried food
recently
Works as sewer
Considers work as a form
of exercise
 OB - GYNE HISTORY

G4P3 (3012), with placenta previa during last menstruation

Menarche: 13 years old

Interval: Regular menstruation
Duration: 3- 4 days
Amount: Moderately soaked
Symptoms: (-)
 REVIEW OF SYSTEMS
(-) Loss of appetite, (-) fever, (-) chills, (-) malaise, (-) easy fatigability,
Constitutional (-) weight change

CNS (-) vertigo. (-) syncope, (-) loss of consciousness, (-) paralysis, (-) numbness,
(-) paresthesia (-) loss of memory, (-) confusion, (-) labile mood, (-) headache

HEENT Head: (-) dizziness; (-) vertigo,

Eyes: (-) blurring of vision, (-) double vision, (-) lacrimation, (-)
photophobia,
Ears: (-) earache, (-) deafness, (-) tinnitus,
Nose and (-) change in smell, (-) nose bleeding, (-) nasal obstruction,
Sinuses:
Mouth and (-) gum bleeding, (-) disturbance in taste, (-) sore throat (-)
Throat: hoarseness
Neck: (-) pain, (-) limitation of movement
 REVIEW OF SYSTEMS
Respiratory (-) hemoptysis, (-) wheezing (-) shortness of breath

(-) dysphagia, (-) diarrhea, (-) constipation, (-) hematemesis, (-) melena,
Gastrointestinal (-) hematochezia,

(-) urgency, (-) bladder distention, (-) hematuria, (-) incontinence,

Genitourinary (-) genital discharge
 REVIEW OF
SYSTEMS
Neuromuscular (-) numbness, (-) limitation of movement, (-) pain

(-) bleeding, (-) pallor, (-) easy fatigability

Hematopoeitic

(-) intolerance to heat and cold, (-) excessive weight gain or loss,
Endocrine (-) polyuria, polydipsia
 PHYSICAL
EXAMINATION
General Survey
Conscious, coherent, not in cardiorespiratory distress with the following vital signs:

BP:160/100 mmHg CR:80 bpm RR:16 cpm

Temperature: 36.0oC Oxygen Saturation: 98% at room air

Integumentary
Skin is fair, moist with sweat, and with good elasticity and skin turgor. No vascularities,
petechiae, purpura, bruises or ecchymosis noted. No rashes and pallor. Body hair is black
in color, thin with fine texture and evenly distributed on upper and lower extremities. Nails
are pinkish, short, clean, no cyanosis and no clubbing. Nail beds are pinkish with no
swelling and have a good capillary refill of less than 2 seconds.

Head
Hair is thick, black, with scanty gray hair, evenly distributed, no masses or tenderness;
temporal arteries are not visible but equally palpable.
 PHYSICAL EXAMINATION
Eyes
Eyebrows are black, thin evenly distributed, no erythema and no lesions noted; palpebral
fissures symmetrical; eyelashes are thin, with outward direction of growth, no matting,
pink palpebral conjunctiva, anicteric sclera, transparent cornea, pupils are 3mm equally
round and reactive to light. Fundoscopy: (+) ROR, AV ratio 2:3, no hemorrhages, no
papilledema. No exophthalmos, or enophthalmos.

Ears
Auricles are symmetrical and non-tender; auditory canals are patent, no discharge;
tympanic membrane is pearly white, with visible cone of light.

Nose and Paranasal Sinuses

Nose is symmetrical, with patent vestibules, mucosa is pink and moist, septum is at the
midline and intact, turbinates are not congested, no discharge, no tenderness over the
frontal and maxillary sinuses.
 PHYSICAL EXAMINATION
Mouth and Oral Cavity
Lips are dry, buccal mucosa and gums are pink and moist, no lesions. Tongue is at the
midline, no fasciculation. Hard and soft palate are pinkish; uvula is at midline. Tonsils are
not enlarged; pink tonsillar walls with no exudates

Neck
Symmetrical, no neck vein engorgement, no palpable cervical lymph nodes, no
tenderness.

Chest and Lungs

Skin is brown, no lesions, no dilated superficial blood vessels, bony thorax is elliptical,
symmetrical chest expansion, no retractions, no lagging, no tenderness, vesicular breath sounds.
 PHYSICAL EXAMINATION
Cardiovascular
Adynamic precordium, no heaves nor thrusts, no palpable thrills. The apex beat is at the
5th intercostal space midclavicular line, normal rate, regular rhythm, no murmur, no neck
vein distention. S1 louder than S2 at the apex. No S3 or S4.

Abdomen
Round, flabby abdomen, no superficial blood vessels, no visible pulsations, normoactive
bowel sounds, no bruits on the epigastric and periumbilical areas, tympanitic, liver span
8cm, soft, no masses, no tenderness.

Extremities

Normal gross ext, full equal pulses, (-)cyanosis, pink nail bed, CRT<2sec
 PHYSICAL EXAMINATION
Neurologic
Cerebrum
Patient is conscious, coherent, oriented to time, place and person.

Cranial Nerves
CN l: not done
CN II: not done
CN III, IV, VI: 2-3 mm pupils equally reactive to light direct and consensual. Intact
extraocular muscles.
CN V: intact V1-V3, good tone and strength of temporalis and masseter
CN VII: no facial asymmetry
CN VIII: can hear on both ears
CN X: uvula is at the midline
CN XI: can turn head from side to side, can shrug both shoulders.
CN XII: tongue is at the midline, no fasciculations
 PHYSICAL
EXAMINATION
Neurologic
Cerebellum (+) Finger to nose test, heel to shin test
(+) Alternating hand movement on his right forearm
(+) Able to stand with support

R L R L R L

4/5 5/5 100% 100% ++ ++

4/5 5/5 100% 100% ++ ++

Motor Sensory DTR

Meningeal Signs (-) Nuchal rigidity, (-) Brudzinski, (-) Kernig’s

Pathologic Reflexes (-) Babinski
03
SALIENT
FEATURES

You could enter a subtitle here if you need it

 HISTORY PE
● Motor Function: 4/5 on Right upper
● 51 year old/ female and lower extremity
● CC: right sided body weakness ● BP = 160/100 mmHg
● (+) facial asymmetry and slurring of ● (-) Other Neurologic findings:
speech Unremarkable
● BP = 186/94 mmHg

● FMHx = Maternal Hypertension

● Recent consumption of fried foods

● PSHx = sewer (considers work as

her exercise)
DIFFERENTIA
L DIAGNOSIS
You could give a brief description of
the topic you want to talk about here
WHAT IS THE LESION?
 HYPOGLYCEMIA
RULE IN RULE OUT

● 51 year old ● Non diabetic

● (+)right sided body ● (-) palpitations
weakness ● (-) tremors
● No food intake prior ● (-) anxiety
experiencing symptoms ● (-) sweating
● CBG to fully rule out
 HEMORRHAGIC STROKE
RULE IN RULE OUT

● 51 year old ● (-) headache

● (+)right sided body ● (-)vomiting
weakness ● (-)impaired consciousness
● (+)facial asymmetry ● Unremarkable neurologic
● (+)slurring of speech findings
● BP = 186/94 PTA ● Cannot fully rule out
● BP upon examination = without imaging
160/100 mmHg
(Hypertension stage 2)
● Physical inactivity
 ISCHEMIC STROKE
RULE IN RULE OUT

● 51 year old ● Cannot fully rule out

● (+)right sided body without imaging
weakness
● (+)facial asymmetry
● (+)slurring of speech
● BP = 186/94 PTA
● BP upon examination =
160/100 (hypertension
stage 2)
● Physical inactivity
 TRANSIENT ISCHEMIC ATTACK
RULE IN RULE OUT

● 51 year old
● (+)right sided body Cannot fully rule out without
weakness imaging
● (+)facial asymmetry
● (+)slurring of speech
● Physical inactvitiy
● ROSIER score = 4
● BP = 186/94 mmHg PTA
● BP upon examination =
160/100 mmHg
(hypertension stage 2)
● Motor Function: 4/5 on
Right upper and lower
extremity
 INITIAL
IMPRESSION

TRANSIENT ISCHEMIC
ATTACK
DISCUSSI
ON
 CEREBROVASCULAR DISEASE
● abrupt onset of a neurologic deficit that is attributable to a focal vascular cause
● Brain imaging study to determine if the cause of stroke is ischemia or hemorrhage

TIA STROKE

Neurologic signs and symptoms Neurologic signs and symptoms last

resolve within 24 h without evidence for >24 h or brain infarction is
of brain infarction on brain imaging demonstrated

Source: Harrison’s Principles of Internal Medicine 20th Ed.

TRANSIENT ISCHEMIC ATTACK

‘acute neurovascular
syndrome’

temporary blockage of blood

flow to the brain

duration is <24 h, but most TIAs

last <1 h
 EPIDEMIOLOGY
● In the US -- around half million/yr
○ 1.1 per 1000 in the US population
$35

Internationally, the
probability of a first TIA
is around 0.42 per
1000 population in
developed countries

PREMIU
M
Source: Panuganti KK, Tadi P, Lui F. Transient Ischemic Attack. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459143/
 ETIOLOGY OF TIA

arise from emboli to the brain

or from in situ thrombosis of
an intracranial vessel

Source: Harrison’s Principles of Internal Medicine 20th Ed.

 ETIOLOGY OF ISCHEMIC STROKE

1 3 5

LARGE ARTERY STROKE OF OTHER

SMALL VESSEL
ATHEROSCLER UNDETERMINED
OCCLUSION ETIOLOGY
OSIS
clinical and brain
imaging findings of 2 4
either significant patients whose strokes
cause of a stroke cannot
(>50%) stenosis or are often labeled as
be determined with any
occlusion of a major lacunar infarcts in other
STROKE OF OTHER degree of confidence
brain artery or CARDIOEMBOL classifications
branch cortical artery, DETERMINED
presumably due to ISM ETIOLOGY
atherosclerosiS
patients with rare causes
patients with
of stroke, such as
arterial occlusions
nonatherosclerotic
presumably due to an
vasculopathies,
embolus arising in the
hypercoagulable
heart
states, or hematologic
disorders

Source: Harold et. al. (2021). Classification of of Subtype of Acute Ischemic Stroke Vol 24, No 1. Retrived from
https://www.ahajournals.org/doi/pdf/10.1161/01.STR.24.1.35
 CLINICAL SIGNS AND SYMPTOMS
Weakness, numbness or
paralysis on one side of Slurred speech
the body

Loss of balance or
Dizziness
coordination

Severe headache
Blindness in one or
with no apparent
cause
both eyes

Source: Harrison’s Principles of Internal Medicine 20th Ed.

 RISK FACTORS

NON Older age Hypertension MODIFIABLE

MODIFIABLE Male High cholesterol

Ethnicity
Cardiovascular diseases
Family history of
Diabetes
stroke

Excess weight
Cigarette smoking

Physical inactivity
Poor nutrition
Heavy drinking
Source: Harrison’s Principles of Internal Medicine 20th Ed.
 PATHOPHYSIOLOGY
EMBOLISM
ARTERIAL STENOSIS
ATHEROSCLEROTIC RUPTURE
DURATION <24 HRS

DECREASED RESTORATI
TRANSIE DECREASE OXYGEN ON OF
IN DELIVERY DISAPPEARA
NT CEREBRAL AND
BLOOD
NCE OF
CEREBRAL FLOW
ISCHEMIC ISCHEMIA NUTRIENTS WITHIN
NEUROLOGIC
BLOOD TO BRAIN SYMPTOMS
STROKE FLOW TISSUE
MINUTES
TO HOUR

RISK FACTORS: No evidence of necrosis

● HYPERTENSION or apoptosis of brain
● DM

Source: Harrison’s Principles of Internal Medicine 20th Ed.

 CEREBROVASCULAR DISEASE
ISCHEMIC HEMORRHAGIC

Acute arterial occlusion S tructural lesions

M edications
Deficit maximal at onset A myloid angiopathy
S ystemic diseases
Atherothrombotic stroke: H ypertension
usually occurs during U ndetermined cause
sleep

Source: Harrison’s Principles of Internal Medicine 20th Ed.

 LABORATORY DIAGNOSTICS
Assess
Check for hydration status
cardioembolic and kidney For investigation
For function To check for
stroke Rule out function on potential
of any liver
hypoglycemia embolic source
coagulation problems

12L BUN,
ECG CBG APTT, PT CREA SGPT 2D ECHO

CHEST CBC NA, K LIPID FBS PLAIN

X RAY PROFILE CT
SCAN

To check for To rule any To assess

anemia and electrolyte To evaluate blood sugar
To detect thrombocytosis imbalance cardiovascular levels
cardiomegaly To rule out
health
hemorrhagic
stroke

Source: Harrison’s Principles of Internal Medicine 20th Ed.

 IMAGING: PLAIN CRANIAL CT SCAN

Hypo attenuating
Obscuration of the Dense MCA sign
brain tissue
lentiform nucleus

Insular
Ribbon sign

Hemorrhagic
infarcts
 BRAIN IMAGING: MRI DWI

● The most sensitive imaging sequence for detection of brain ischemia is

diffusion-weighted MR imaging, which may turn positive minutes after
infarction begins.

● Thurnher, M. Imaging of Acute Stroke. Medical University of Vienna. Retrieved from

https://radiologyassistant.nl/neuroradiology/brain-ischemia/imaging-in-acute-stroke
 OVERVIEW OF MANAGEMENT
Provide basic emergent Monitor and manage BP,
supportive care (ABCs of
01 treat if (MAP >130 mmHg)
Resuscitation
02 Precautions:
Avoid precipitous drop in
Monitor neuro-vital signs, 03 BP (not > 15% of baseline
BP, MAP, RR, MAP)
Temperature and pupils
04
Do not use rapid acting
sublingual agents. Use
Perform Stroke Scales 05 easily titratable IV or short
(NIHSS, GCS) acting oral
06 antihypertensive

Perform Risk Ensure appropriate

Stratification using the hydration. Recommended
ABCD2 Scale IVF 0.9% NaCl if needed
Reference: The Stroke Society of the Philippines, Guidelines for the Prevention, Treatment and Rehabilitation of Stroke, 5th edition
 ABCD2 RULE

Reference: The Stroke Society of the Philippines, Guidelines for the Prevention, Treatment and Rehabilitation of Stroke, 5th edition
MANAGEME
NT
Surname: xx Age:51 Hospital number 123456

First name: x Sex: F Ward: IM

Date/ Time Progress Notes Doctor’s Orders

03/04/21 S> ➢ Please admit to Acute Stroke Unit under the service of Dr.
(-) headache Domingo/Dr. Lisay/Dr. Artillera/ Dr. Fernando
(-) body weakness ➢ Secure consent for admission and management
➢ History and physical examination done by PGIs
(-) slurring of speech
➢ IVF: 0.9% NaCl 1L to run at 90cc/hr
(-) nausea
➢ NPO temporarily
(-) vomiting
(-) loss of consciousness # Transient Ischemic Attack
(-) visual disturbances Diagnostics:
❏ Cranial MRI with DWI/Plain Cranial CT Scan
❏ CBC
O> ❏ Serum electrolytes (Na, K, Cl, Mg, Ph)
BP: 160/100 mmHg ❏ BUN, Creatinine
❏ CBG, FBS, lipid profile
CR: 80 bpm
❏ PT, PTT
RR: 16 cpm
❏ 12L ECG with long lead II
T: 36.0 C ❏ Chest Xray PA
02 Sat: 98% at room air ❏ 2D echo

MAP: 120 mmHg Therapeutics:

GCS 15 (E4V5M6) ❏ Aspirin 160mg/day for 14 days

NIHSS 0 ❏ Standby IV Nicardipine 1-1.5mg/hr for MAP >130
Reference: The Stroke Society of the Philippines, Guidelines for the Prevention, Treatment and Rehabilitation of Stroke, 5th edition
 Surname: xx Age:51 Hospital number 123456

First name: x Sex: F Ward: IM

Date/ Time Progress Notes Doctor’s Orders

03/04/21 S> ➢ Please admit to Acute Stroke Unit under the service of Dr.
(-) headache Domingo/Dr. Lisay/Dr. Artillera/ Dr. Fernando
(-) body weakness ➢ Secure consent for admission and management
➢ History and physical examination done by PGIs
(-) slurring of speech
➢ IVF: 0.9% NaCl 1L to run at 90cc/hr
(-) nausea
➢ NPO temporarily
(-) vomiting
(-) loss of consciousness # Transient Ischemic Attack
(-) visual disturbances Diagnostics:
❏ Cranial MRI with DWI/Plain Cranial CT Scan
❏ CBC
O> ❏ Serum electrolytes (Na, K, Cl, Mg, Ph)
BP: 160/100 mmHg ❏ BUN, Creatinine
❏ CBG, FBS, lipid profile
CR: 80 bpm
❏ PT, PTT
RR: 16 cpm
❏ 12L ECG with long lead II
T: 36.0 C ❏ Chest Xray PA
02 Sat: 98% at room air ❏ 2D echo

MAP: 120 mmHg Therapeutics:

GCS 15 (E4V5M6) ❏ Aspirin 160mg/day for 14 days

NIHSS ❏ Standby IV Nicardipine 1-1.5mg/hr for MAP >130
Reference: The Stroke Society of the0Philippines, Guidelines for the Prevention, Treatment and Rehabilitation of Stroke, 5th edition
Surname: xx Age:51 Hospital number 123456

First name: x Sex: F Ward: IM

Date/ Time Progress Notes Doctor’s Orders

03/04/21 S> ➢ Please admit to Acute Stroke Unit under the service of Dr.
(-) headache Domingo/Dr. Lisay/Dr. Artillera/ Dr. Fernando
(-) body weakness ➢ Secure consent for admission and management
➢ History and physical examination done by PGIs
(-) slurring of speech
➢ IVF: 0.9% NaCl 1L to run at 90cc/hr
(-) nausea
➢ NPO temporarily
(-) vomiting
(-) loss of consciousness # Transient Ischemic Attack
(-) visual disturbances Theraputics (continuation):
Secondary prevention:
➢ For carotid ultrasound as OPD basis
O> ➢ Aspirin 25 mg + dipyridamole 200 mg BID
BP: 160/100 mmHg ➢ Encourage lifestyle changes: DASH diet, aerobic exercise 20-
60mins daily 3-7 days a week
CR: 80 bpm
RR: 16 cpm
Refer accordingly.
T: 36.0 C
02 Sat: 98% at room air

MAP: 120 mmHg

GCS 15 (E4V5M6)
NIHSS 0 Reference: The Stroke Society of the Philippines, Guidelines for the Prevention, Treatment and Rehabilitation of Stroke, 5th edition
CONCEPT MAP
MERCUR
Y
Mercury is the closest
planet to the Sun

VENUS
Venus has a beautiful name,
but it’s terribly hot

MARS
Despite being red, Mars is
actually a cold place
TAKE HOME MESSAGE
● TIA is a transient episode of neurological dysfunction
without evidence of acute infarction in which clinical
symptoms typically last less than an hour
● Accurate History and Physical Examination, exclusion of
stroke mimickers and use of Neuroimaging ascertain the
clinical diagnosis for type of stroke
● Early recognition of signs and symptoms of stroke leads to
early intervention so always remember BEFAST: Balance
Loss, Eyesight Change, Face Drooping, Arm Weakness,
Slurred Speech, Time to call 911
● Lifestyle modification such as eating healthy foods and
regular exercise is a cost effective measure in preventing
stroke
 THANK
YOU FOR
LISTENING
!
and STAY
SAFE!
 REFERENCES
● Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson, J. L., & Loscalzo,
J. (2018). Harrison's principles of internal medicine (20th edition). Vol.1 & Vol.2
(ebook). McGraw Hill Professional.

● Stroke Society in the Philippines. (2011). Guidelines for the Prevention, Treatment
and Rehabilitation of Stroke (5th edition). GoldenPages Publishing Company

● Thurnher, M. Imaging of Acute Stroke. Medical University of Vienna. Retrieved from

https://radiologyassistant.nl/neuroradiology/brain-ischemia/imaging-in-acute-stroke

● Harold et. al. (2021). Classification of of Subtype of Acute Ischemic Stroke

Vol24,No1.Retrived from https://www.ahajournals.org/doi/pdf/10.1161/01.STR.24.1.35

● Panuganti KK, Tadi P, Lui F. Transient Ischemic Attack. [Updated 2021 Jul 27]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK459143/