C. B. 71 year old, male Right handed Married Filipino RC Retired mechanic supervisor

1. GR

2. C. B. • 71 year old, male • Right handed • Married • Filipino • RC • Retired mechanic supervisor • Makati City • CC: right sided weakness

3. History of Present Illness

4. Ospital ng Makati • PE: • NE:GCS 11 (E4V1M6)2-3 ERTL, (+) EOMS, (+) corneal reflex, shallow left NLF, (+) hearing, (+) gag reflex, lag (L), tongue deviation (L) • Impression: stroke • Meds: Citicoline 2g/IV • Cranial CT: bilateral basal ganglia infarct • CXR: cardiomegaly • ECG: non specific ST waves changes

5. History of Present Illness

6. Review Of Systems • (-) weight loss, (-) fever, (-) anorexia • (-) skin rashes, (-) itchiness • (-) redness of eyes, (-) blurring of vision • (-) deafness, (-) tinnitus • (-) epistaxis • (-) bleeding gums • (-) cough, (-) colds, (-) dyspnea, (-) hemoptysis • (-) chest pain, (-)orthopnea, (-) palpitations • (-) abdominal pain, (-) hematemesis, (-) diarrhea, (-) constipation • (-) dysuria, (-) nocturia, (-) frequency

7. Past Medical History • (+)HPN since 2006 maintained on Isosorbide dinitrate (Isordil) • (-) DM, asthma, allergies, PTB, kidney disease, liver disease, heart disease, seizure • No known exposure to PTB

8. Family History • (+) HPN, stroke, DM - mother

9. Personal & Social History • Diet: mixed • Smoker 40 pack years • Occasional alcoholic drinker • Denies illicit drug use

10. PE • Conscious, coherent, bedridden, in cardiorespiratory distress • BP: 160/90 PR: 86 bpm, regular RR: 20 cpm T: afebrile • Warm, moist skin, no active dermatoses • Pink palpebral conjunctivae, anicteric sclerae • Pupils 2-3 mm ERTL, anicteric sclerae • Moist buccal mucosa, no oral lesions, nonhyperemic posterior pharyngeal wall, tonsils not enlarged

11. PE • Supple neck, no palpable CLN, no carotid bruit • Symmetrical chest expansion, no retractions, clear breath sounds • Adynamic precordium, AB at 5th LICS MCL, no murmurs • Flabby abdomen, normoactive bowel sounds, no palpable mass, no tenderness • Pulses full & equal, no cyanosis, no edema

12. NEUROLOGICAL EXAMINATION • OSPITAL NG MAKATI • BP 180/90, PR 73, RR 20, Temp 36.8C • GCS 11 (E4V1M6) • 2-3 ERTL, (+) EOMS • (+) corneal reflex • shallow left NLF • (+) hearing • (+) gag reflex • lag (L) • tongue deviation (L) • USTH • Alert, awake, dysarthric, follows some commands, GCS 11 (E4V1M6) • Pupils 3-4 mm ERTL, isocoric, (+) visual threat, (+) dysconjugate gaze • V1-V3 intact • (+) shallow right nasolabial fold • Gross hearing intact • Can shrug shoulders • MMT 5/5 LUE, LLE; 1/5 RUE; 0/5 RLE • Cerebellum cannot be assessed • DTRs ++ on all 4’s • No sensory deficits • (+) Babinski right • No nuchal rigidity

13. Salient features: • SUBJECTIVE • 71 y/o male • Right sided weakness • (+) hypertensive for 3 years • (-) hx of seizure • Smoker 40 PY • (-) trauma • (-) numbness/paresthesia • (-) autonomic disturbances • OBJECTIVE • Dysarthric • Shallow right NLF • MMT: 5/5 on both left upper and lower extremities; 1/5 on RUE, 0/5 on RLE

14. Initial Assessment • Is there a neurologic problem? • Where is the lesion? • What is the lesion?

15. Is there a neurologic problem? • Increased ICP • Headache/vomiting • Papilledema • Meningeal irritation • Headache/vomiting • Nuchal rigidity • Brudzinski and Kernig sign

16. Is there a neurologic problem? • Focal neurologic deficit • Seizure • Dysarthria • Shallow right NLF • MMT: 5/5 on both left upper and lower extremities; 1/5 on RUE, 0/5 on RLE • (+) Chaddock’s, right

17. Where is the lesion?

18. Levelization, Lateralization, Localization

19. Levelization • MMT: 5/5 on both left upper and lower extremities; 1/5 on RUE, 0/5 on RLE • (+) Chaddock’s right • upper motor neuron

20. Levelization • Upper Motor Neuron • cerebrum • cerebellum • brainstem • spinal cord

21. Levelization • autonomic dysfunction • sensory level to pain • spinal cord

22. Levelization • crossed sensory/ motor • brainstem

23. Levelization • Dysarthric • Shallow right NLF • MMT: 5/5 on both left upper and lower extremities; 1/5 on RUE, 0/5 on RLE • cerebrum

24. Shallow right NLF MMT: 5/5 on both left upper and lower extremities; 1/5 on RUE, 0/5 on RLE Lateralization • left

25. Localization • seizures • dysarthric • Shallow right NLF • MMT: 5/5 on both left upper and lower extremities; 1/5 on RUE, 0/5 on RLE • Frontal lobe

29. Levelization: cerebrum • Lateralization: left • Location: frontal lobe

30. What is the lesion? • Onset: acute • Course: Progressive • Type: Focal • Etiology: cerebrovascular

32. Atherothrombotic Infarction • paralysis or other focal deficits is preceded by minor signs of one or more transient attacks of focal neurologic dysfunction, or TIAs (Transient Ischemic Attacks) • In the carotid and middle cerebral artery disease, the transient attacks consist of monocular blindness or of hemiplegia, hemianesthesia, or disturbances of speech and language.

33. Atherothrombotic Infarction • In the vertebrobasilar system, the prodrome often take the form of episodes of vertigo, diplopia, numbness, impaired vision in one or both visual fields and dysarthria • TIAS last from a few minutes to several hours • In most instances the duration is less than ten minutes.

34. Atherothrombotic Infarction • Final stroke may be preceded by one or two attacks or a hundred or more brief TIAs and the stroke may follow the onset of the attacks by hours, days, or less frequently by weeks or months • Single episode but the whole illness evolves over a few hours or less • “Stuttering” or intermittent progression of neurologic deficits extending over several hours or a day or longer is a characteristic

35. Embolic Infarction • most common cause of stroke • emboli from the heart in patients with already-existing heart disease • chronic or recent atrial fibrillation • focal neurologic deficit is abrupt in onset

36. Hemorrhage • abrupt and potentially devastating • headache • increased intracranial pressure • nausea and vomiting.

37. ACA vs MCA

39. Oxfordshire Classification of Stroke