CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE

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MEDBACK Bifurcate -> naghiwalay
Hemiparesis where

Non-vascular (brain pathology) etiology

- Seizure
- Cerebral abscess/infection
(space-occupying lesions
examples: tumor, subdural
hematoma)
- Trauma
- Syncope
- Infection
- Encephalitis
- Somatization
- Delirium secondary to sepsis
*other neurologic deficits
2/3 of the brain supplied by -> Anterior
Most common: D/Dx: Seizures Circulation
Manifestation: Aphasia -> Internal
Circle of willis Carotid Artery
1/3 of the brain supplied by -> Posterior
Circulation
Manifestation: CN involvement: nauutal,
duling
dysarthria (slow and slurred speech) ->
posterior circulation -> (Karamihan ng
CN arise from the brainstem) ->
Brainstem is supplied by posterior
circulation
Nagjoin yung verterbral – basilar ->
vertebrobasilar arteries -> supply the 1/3
-> posterior circulation

Cerebral Edema/Hemorrhage ->

increase ICP -> increase (brainstem)
Herniation -> Death

SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
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Namamaga brain mo -> mataas
pressure (ICP) -> titigil
Embolism (blood clots and affects our
health common in the heart) -> anong
sakit sa heart ang nakaka-embolism? ->
Atrial Fibrillation
Ang blood kailangan tumatakbo ‘yan ->
kapag tumitigil ang takbo ng blood ->
doon nagfoform ng thrombus -> doon
nanggagaling ang blood clot
Bakit nabuo yung thrombus doon na
natanggal -> to become an embolus ->
Atrial Fibrillation -> pwede yung moi?
namatay yung portion ng heart kaya
hindi na tumitibok -> hindi lang
tumitibok, nanginginig pa
Coronary artery is MI -> kaya namatay
yung heart kasi coronary artery doon
yung nagsusupply sa heart muscles
Hypoperfusion -> imbis na pumutok,
imbis na magbara -> hindi na
dumadaloy yung bloodflow to the brain -
> therefore, sa isang stroke pt. -> hindi
pinapababa yung blood pressure ng
sobra ->
BP = 140/90 (maintaining sa stroke pt.)
Hindi po ba highblood ‘yan? Yes, but in
a stroke pt., if you further lower it instead
of the brain regaining blood flow mas
lalong nababawasan kapag sobrang
baba ang BP.
Ischemia -> kulang na sa dugo -> lalong
nauuhaw yung brain mo -> intervention
is BP hindi pinapababa below 140/90
Stroke which affects penetrating (maliliit)
arteries -> Lacunar Stroke
Small penetrating arteries -> Lenticulo-
striate arteries
Why Contralateral manifestation in
stroke?
Bakit ang stroke kapag natamaan sa’yo
is right brain, yung manifestation niya is
kabilang part ng brain?
Decussation -> nagcross
Ex: yung kamay ko para gumalaw ‘yan,
syempre may mag-uutos dyan -> BRAIN
-> yung nag-uutos dyan nasa opposite
side -> para mapunta siya dyan may
dadaanan siyang tract ->
CORTICOSPINAL TRACT -> (brain to
spinal cord = corticospinal) kaya lang AT
THE LEVEL OF MEDULLA nagcross
siya to the opposite side = explanation
kung bakit contralateral siya
Ex: kunwari siya naman hahawakan
niya ko -> ba’t niya ko hahawakan? ->
para maramdaman ko naman ‘yon =
kailangan maramdaman ng kamay ko ->
iaakyat niya sa AREA 2 ng BRAIN ko ->
SPINOTHALAMIC TRACT -> nagcross
din sa level ng (kapag sa level ng
SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
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sensory, pagpasok sa level ng spinal
cord) sa level of C5, 2 akyat lang siya
magcross na siya -> contralateral
weakness, contralateral hemisensory
loss
Pwede ba ang stroke ay IPSILATERAL?
Ex: Meron bang lesion sa left side of the
brain tapos ang manifestation nasa left
side rin?
Based sa inaaral natin -> lesions in the
brainstem can be ipsilateral,
contralateral, bilateral = kasi manipis
ang brainstem, minsan doon nga
nangyayari yung decussation eh
CT Scan -> most commonly used, is the
only test that can detect presence of
blood -> unang oras ng stroke
napakahalaga malaman if this is
hemorrhagic or not -> because mataas
ang mortality rate ng hemorrhagic stroke
Given the choice, 1st test you should
request is -> CT SCAN
Mas mahalaga madetect if hindi
hemorrhagic ang stroke kesa sa small
infarct.
MRI -> what imaging test can detect
small infarct?
Diabetes Mellitus (DM) -> accelerated
atherosclerosis -> early pathophysiology
of stroke -> kasi magbabara ang artery
mo kapag merong plaque & blood clot
Plaque -> nanigas na cholesterol
Ang magsasara talaga is yung blood
clot, not plaque mismo
Fibrin
Embolus (sa puso)
IE NOTES
SUBJECTIVE
Diagnosis:
Formal diagnosis -> CVD na, not stroke
CAD = heart
Make it less wordy = “nahihirapan
siyang gawin yung trabaho niya bilang
chef” -> no need na sabihin na “tulad ng
pagkuha niya ng mga pinggan, etc” ->
we do not want the IE/chart to be very
long
Informant -> is the wife? Why not the
patient?
Pt. has slurred speech (I can still say
what I want but not in a very clear
articulation, pero tama pa rin yung
isasagot ko sa’yo kung tatanungin mo
ako) = pwede pa kayong
magkaintindihan
The best source of information is always
the patient -> how can you ask the wife -
> what is the Glasgow coma scale?
NIHSS? (PATIENT ang source) ->
malamang may other sources ka ng
information -> patient, caregiver, wife,
chart -> if you want mas accurate pa ->
even the doctor, nurse, etc -> since, ang
main purpose is how to treat the patient
SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
DOC GO NOTES
After n weeks -> we need to know if the Fluid -> gives hyperintense
patient is bedridden? Can the patient sit
CT scan -> fluid -> hyperdensity
up? Can the pt. ambulate?

Blood chemistry -> blood sugar,

As PT -> we are not only interested in
the medical tx -> how was he after the
incident? Mobility? Function?
At present, there is weakness, there is
numbness -> diba patient ang
magsasabi niyan? Hindi yung wife.
(mobility, e.g. all other aspects of
selfcare are provided by the caregiver)
Ancillary procedures
CT Scan -> cannot determine the
percentage of occlusion
Only Angiography, arteriography -> can
determine percentage of occlusion
*kanina yung pinakita na image of brain
na may kulay puti -> white ->
hemorrhage -> you will describe that as
hyperdense area (ex: in the left basal
ganglia)
Xray description
Lucency – kulay itim
Density – kulay puti
CT Scan
Hypodense – itim
Hyperdense – puti
MRI Scan
Hyperintense – puti
Hypointense – itim
cholesterol, creatinine
High/elevated cholesterol -> risk for
atherosclerosis -> risk factor of stroke ->
atherosclerosis
FBS -> fasting of 10 hrs, mumog lang
HBA1C test -> accurate, past 3 months
(average) of blood glucose -> a.k.a
Glycosylated Hemoglobin Test
Most important electrolyte -> nagbibigay
sa’yo ng pagkalito, walang malay ->
SODIUM (asin)
What is important to know in
ROSUVASTATIN/ATORVASTATIN?
Side effects: Muscle pain and joint pain
*nakarelax lang ako sa bahay, walang
ginagawa pero masakit pa rin likod ko ->
ipatigil mo yung rosuvastatin etc baka
mawala mm pain niya
ASPIRIN -> not an anti-coagulant (iniiba
mo dyan is yung clotting factor), is an
anti-platelet drug -> it prevents platelet
aggregation
*pinakamura pero maraming side
effects, 50 cents
*CLOPIDOGREL -> kapalit ng aspirin
*kung ikaw ay may family history, lahat
sila namatay d/t stroke -> highblood ka
ba? Yes -> bibigyan ka na agad ng
maintenance na either aspirin or aspilet

SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
DOC GO NOTES
or clopidogrel -> kahit hindi ka pa
nastroke kasi mataas yung family hx mo
na magkaron ka
Past medical history
Why are you asking for COVID-19? For
safety purposes
Covid 19 not related to stroke
Family history -> nilalagay is medyo
pertinent or related sa case -> ex: DM,
Hypertension (risk factor), Atrial
fibrillation (cause of thrombus kapag
wala sa brain, nasa heart ang tawag is
embolus)
RA -> causes stenosis of arteries ->
plaque build up -> atherosclerotic
plaque -> lipid/fats, cholesterol,
collagen, proliferating intimal cells
(tunica intima)
Atherosclerotic plaque -> Tunica Intima,
taba, cholesterol
Anemia -> mababa hemoglobin ->
kulang sa o2 -> o2 carrying substances
of the blood = hemoglobin -> pump nang
pump yung puso para dagdagan yung
supply
Thrombus formation
Paano nagiging malapot ng dugo? Pag
maraming cells yung blood ->
Polycythemia (erythrocytosis)
Liquid part of blood -> plasma
Cell part -> RBC, WBC, platelets
(thrombocytosis)
Cancer can cause increased viscosity of
the blood
Family history -> Stroke, heart disease,
DM -> you cannot do anything about it
PSEHx -> what will happen to the
patient? Makakabalik ba siya sa
trabaho? Kailangan alamin niyo ‘yon
Pag dinischarge si pt. -> naka-WC,
assistive device, bedridden?
Mobility sa bahay -> kasya ba siya
*kusina/stairs* if ever pupunta siya
doon?
OBJECTIVE
Normal vital signs *IE ng grp 1* pero
ang significance nila -> in the future,
elevated measurements will be (look for
any of) d/t patient’s discomfort -> eh
normal yung vital signs?
Significance -> what does Significance
tell you? Kapag may abnormal findings
ka ano yung dahilan? Pano naka-affect
ito sa patient? Ano plan mo to correct
that as PT?
*pwede mo ba ituloy yung exercise
niya? YES pt. can do sitting, standing
balance and so far the VS is normal
*unless kapag may abnormal findings
titignan ko ulet if makakatayo siya or
makakaupo
OI -> nasa huli yung positive, pertinent
postural and gait details
*pagtapos nung positive, pertinent saka
mo ilalagay yung negative, pertinent
details (i-expect mo siya pero buti na
lang negative)
SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
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Ano ibig sabihin na ambulatory
hemiwalker? Right side? Is it a complete
walker?
Proprioception -> what part of body do
you test? Most distal joint in Upper limb -
> DIP jt of index finger
Most distal jt in Lower limb -> IP jt of big
toe
Kapag hindi normal saka ka aabante pa-
proximal -> MCP of thumb/index
finger/wrist then ankle joint of foot

Bakit naghahanap kayo ng decubitus

ulcer?
In a pt. who is bedridden or on WC? Is It
pertinent? YES
In an ambulatory pt.? NO
PALPATION -> lagyan findings and
siginificance
Hypertonic -> anong grade?
Muscle tightness -> anong side? R or L?
Subluxation -> usually in SH, flaccid,
tight -> (+) or (-) nilalagay because its
pertinent
Hypertonicity -> ano effect nito? Ano tx
mo as PT?
How can you say that the pt. presents
intact R UE when the score is 9/10? So
dapat not intact, gawin na lang 10

SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
DOC GO NOTES
If you have sensory deficit sa kamay ->
Why is it important to know? Para lang
ba hindi mapaso? What else? Clumsy
(manhid kamay -> makakabitaw ka ng
gamit) -> you need tx and even
protection
Affected proprioception -> kinesthesia
and vibration -> significance -> pt. has
increase risk of wrist injury and impaired
UE sensation affects ADL
One important significance of
proprioception deficit -> Standing
balance -> balance problems
Cranial Nerve
Corneal reflex -> test of 2 CN
Sensory part -> CN V -> touch the
cornea using cotton?
Response -> blinking, another CN -> CN
VII
Opening eye -> CN III
Closing eye -> CN VII
CN VII -> vestibulocochlear
Ba’t hindi tinest cochlear -> bakit hindi
nilagay sa results and findings?
If you have proprioceptive
deficit/cerebellar lesion -> (+) Romberg’s
But you are testing for CN VIII ->
DTR -> testing for stretch-reflex
Hyperreflexia -> UMN -> abnormal movt,
abnormal walking -> wag LOM
SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
DOC GO NOTES
Tone Assessment ->
Modified Ashworth Scale – spasticity
*magkaiba MAS sa hypertonicity scale?
Range of Motion
When writing findings when you talk of
ROM, you cannot say 70 degrees it
must be a range ->
If grade if spasticity is 2 -> can you
complete the ROM? Rom is limited in
range
Tone is 1 ->
Treatment for spasticity and ROM
limitation -> ROMEs, stretching and
strengthening
Bobath, PNF -> can also help
MMT
Break testing -> resist yung resistance
na biinibigay ng PT
Ano difference sa usual MMT?
Bakit ginamit sa both UE and LE? Kahit
normal naman and not severe yung
impairment
Ingat sa initial statement -> kapag iyan
sinabi niyo na it applies to everything or
every IE -> right side is okay, normal, no
deficits -> MMT pwede na gamitin
usual/classic, sa affected side ayon
pwede break testing or modified tests
Anthropometric measurement ->
Null -> where in this table can you see
the word null? -> no legend for null ->
suddenly lumabas siya sa findings
FINDINGS -> is just what’s written on
the table, don’t over-interpret
SALANGSANG, K.M.B.
CC2 TOPIC 1: CVD 2° THROMBOTIC STROKE
DOC GO NOTES
SIGNIFICANCE -> interpretation of
findings

SALANGSANG, K.M.B.