Pathophysiology

Nervous System

Case Study

Patient Profile

Name: Jose Martinez

Age: 68 years old

Gender: male

History of Present Illness

J.M. is a 68-year-old man who presents to the emergency room with complaints of sudden onset weakness in his right arm, slurred speech, and difficulty understanding words while at work this afternoon. He denies facial drooping or visual disturbances. These symptoms lasted for about 15 minutes and then resolved. He reports experiencing similar episodes twice in the past month, each lasting 10-15 minutes. He has not sought medical attention for these previous episodes. Mr. Martinez is concerned about these recurring symptoms and seeks advice on what might be causing them and how to prevent them in the future.

Social History

  • Works full time in a printing shop
  • Divorced, remarried seven years ago, three adult children from first marriage live nearby, wife has legal custody of her grandson, age nine, who lives with them full time
  • Denies use of illegal drugs, smokes marijuana 2-3 times per week to manage stress and insomnia, has 2-3 beers on the weekends, current smoker (30 pack-years)

Family History

Father died from a heart attack at age 52, mother died from a stroke at age 72, one living brother, age 60, currently being treated for esophageal cancer.

Past Medical History

Hypertension, hyperlipidemia, type 2 diabetes, smoker (30 pack-years)

Current Medications

Lisinopril, Atorvastatin, Metformin

Physical Assessment

Vitals

  • Blood Pressure: 168/92 mm Hg
  • Heart Rate: 88 bpm
  • SpO2: 96% on room air
  • Point of Care Blood Glucose: 182 mg/dL
  • Recent Blood Tests: Elevated LDL cholesterol and HbA1c of 7.5%

General Survey

  • Mental Status: Alert & oriented x3, speech clear, follows commands appropriately.
  • Cranial Nerve Examination: II-XII intact, no facial asymmetry, visual fields intact, extra-ocular movements normal.
  • Motor Examination: 5/5 strength in all extremities, no current arm weakness, normal grip strength bilaterally.
  • Sensory Exam: Intact to light touch and pinprick, no sensory deficits noted.
  • Coordination: Normal finger-to-nose testing, normal rapid alternating movements, gait steady with no ataxia.
  • Cardiovascular Exam: Right carotid bruit present, heart regular rate and rhythm, no murmurs, peripheral pulses present and symmetric.

Calculation of a Risk Stratification Score

ABCD2 Score – to estimate the risk of a stroke after a suspected transient ischemic attack

A calculator is available at the MDCalc website.

  • Age ≥ 60 years (1 point)
  • BP ≥ 140/90 (1 point)
  • Clinical features: Unilateral weakness (2 points)
  • Duration: 10-59 minutes (1 point)
  • Diabetes present (1 point)
  • Total Score: 6 points – indicating high risk for stroke: 8.1% within 2 days, 11.7% within 7 days, and 17.8% within 90 days

Mr. Martinez is admitted to the stroke unit for observation.

Diagnostic Assessment

Diagnostic testing is ordered, including complete blood count, comprehensive metabolic panel, coagulation profile, lipid panel, HbA1c, and troponin. Patient has a 12-lead electrocardiogram, an MRI with diffusion-weighted imaging, and a carotid Doppler ultrasound while on continuous cardiac monitoring. Cardiology and neurology are consulted.

Diagnosis

Transient Ischemic Attack (TIA)

Activity: Pathophysiology of TIAs

(Options: without, with, cerebral, aortic, vision, auditory, 2, 24)

A TIA, often referred to as a “mini-stroke,” is a temporary period of symptoms similar to those of a stroke. It occurs when there is a brief interruption in the blood supply to part of the brain, spinal cord, or retina, ______________________ causing permanent damage. This transient ischemia is most commonly caused by embolic or thrombotic events, such as atherosclerotic plaque rupture or cardiac embolism, which partially or completely occlude blood flow in a ______________________ artery. Other mechanisms include small vessel disease, arteriolosclerosis, and less common causes like arterial dissection, vasculitis, or hypercoagulable states. Risk factors include hypertension, diabetes, hyperlipidemia, smoking, obesity, sedentary lifestyle, family history of stroke or TIA, and age.

The resulting ischemia deprives affected neurons of oxygen and glucose, impairs their function, and causes symptoms such as weakness, speech disturbances, or ______________________ changes.  Symptoms resolve, without permanent damage, once blood flow is restored, but they indicate an issue with blood flow to the brain.  The recommended timeframe for evaluation and management of a suspected TIA episode is within ______________________ hours of symptom onset.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. What is the primary underlying pathophysiology of a TIA?
    1. Permanent blockage of a cerebral artery.
    2. Temporary reduction in blood flow to a part of the brain.
    3. Hemorrhage in the brain.
    4. Inflammation of brain tissue.
Answer:

B) Temporary reduction in blood flow to a part of the brain.. Feedback: A TIA is caused by a temporary reduction in blood flow to a part of the brain, leading to transient neurological symptoms that resolve within 24 hours.

  1. Which of the following is a common risk factor for a TIA?
    1. Hypotension
    2. Hyperlipidemia
    3. Hypoglycemia
    4. Hypercalcemia
Answer:

B) Hyperlipidemia. Feedback: Hyperlipidemia is a common risk factor for a TIA as it contributes to the development of atherosclerosis, which can lead to reduced blood flow to the brain.

  1. What is the most likely cause of the transient neurological symptoms of a TIA?
    1. Formation of a blood clot in the heart.
    2. Rupture of a cerebral aneurysm.
    3. Temporary blockage of a small blood vessel in the brain.
    4. Chronic inflammation of the meninges.
Answer:

C) Temporary blockage of a small blood vessel in the brain. Feedback: The transient neurological symptoms in a TIA are most likely caused by a temporary blockage of a small blood vessel in the brain, which reduces blood flow and oxygen supply to the affected area.

  1. Which of the following mechanisms can lead to a TIA?
    1. Embolism from a distant site
    2. Chronic hypertension
    3. Hyperglycemia
    4. Hypokalemia
Answer:

A) Embolism from a distant site. Feedback: An embolism from a distant site, such as the heart or a large artery, can travel to the brain and temporarily block a blood vessel, leading to a TIA.

  1. What is the significance of a TIA in terms of future stroke risk?
    1. TIAs have no impact on future stroke risk.
    2. TIAs significantly increase the risk of a future stroke.
    3. TIAs decrease the risk of a future stroke.
    4. TIAs are only significant if they occur more than once.
Answer:

B) TIAs significantly increase the risk of a future stroke.. Feedback: TIAs significantly increase the risk of a future stroke. They are often considered warning signs and indicate the need for immediate medical evaluation and management to prevent an actual stroke.

  1. What is the primary risk factor for developing a TIA?
    1. High physical activity levels.
    2. Increased fluid intake.
    3. Hypertension.
    4. Low cholesterol levels.
Answer:

C) Hypertension. Feedback: Hypertension increases pressure on blood vessel walls, promoting atherosclerosis and increasing the likelihood of blood flow obstruction to the brain.

  1. What is the recommended timeframe for evaluating a patient suspected of having a TIA?
    1. Within 1 hour
    2. Within 12 hours
    3. Within 24 hours
    4. Within 72 hours
Answer:

C) Within 24 hours. Feedback: The recommended timeframe for TIA evaluation is within 24 hours of symptom onset or sooner if possible.

  1. During the initial assessment of a patient with a suspected TIA, which of the following is essential to include?
    1. Scheduling a follow- up appointment with cardiology next week.
    2. Ordering routine blood work.
    3. Performing a focused neurological exam.
    4. Prescribing pain medication.
Answer:

C) Performing a focused neurological exam.. Feedback: A focused neurological exam is crucial for initial TIA assessment.

  1. Use the ABCD2 calculator above and determine the score for the following patient. A 65-year-old patient presents with a speech disturbance that lasted 45 minutes. Their blood pressure is 150/95 mmHg, and they have a history of diabetes. What is their ABCD2 score?
    1. 3 points
    2. 4 points
    3. 5 points
    4. 6 points
Answer:

C) 5 points

Feedback: ABCD2 Score calculation:

  • Age ≥60 years (1 point)
  • BP ≥140/90 (1 point)
  • Speech disturbance (1 point)
  • Duration 10-59 minutes (1 point)
  • Diabetes present (1 point)
  • Total = 5 points

An ABCD2 score of 4-5 places the patient in the moderate-risk category, with a 7-day stroke risk of approximately 4-12%

References

Heavey, E. (2024). Lecture on the Nervous System. [Transcript].

Johnston, S. (n.d.). ABCD2 Score for TIA. Available at: https://www.mdcalc.com/calc/357/abcd2-score-tia

Microsoft. (2024). Copilot [AI assistant]. Microsoft Corporation.

Panuganti KK, Tadi P, Lui F. Transient Ischemic Attack. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459143/

Tkacs, N. (Ed.). (2020). Advanced physiology and pathophysiology: Essentials for clinical practice. Springer Publishing Company.

Rost, N. &Voetsch, B. (2025). Up to Date: Definition, etiology and clinical manifestations of Transient Ischemic Attack. Retrieved from: https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack

Wardlaw, J. M., Brazzelli, M., Chappell, F. M., Miranda, H., Shuler, K., Sandercock, P. A., & Dennis, M. S. (2015). ABCD2 score and secondary stroke prevention: meta-analysis and effect per 1,000 patients triaged. Neurology, 85(4), 373–380. https://doi.org/10.1212/WNL.0000000000001780

You.com. (n.d.). Homepage. You.com. Retrieved February 22, 2025, from https://www.you.com

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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