Quick answer
How should I present an acute stroke case on rounds?
Lead with the exact time of onset, since it decides eligibility for treatment. Give the discriminating deficits—facial droop, arm and leg weakness, and aphasia—then her vascular risks, especially the anticoagulation lapse. State vitals, the NIHSS score, glucose, and imaging findings before naming the leading diagnosis and the specific occlusion. End with the time-critical treatment plan and what still needs to be confirmed.
Before you speak
Define the moment and the information you actually have
A stroke-code presentation immediately after the non-contrast head CT and CT angiography results return.
The stroke team and supervising attending deciding on thrombolysis and thrombectomy eligibility.
History, exact time of onset, vital signs, NIHSS score, point-of-care glucose, non-contrast CT, and CT angiography. Coagulation studies and a full medication-reconciliation history are not supplied.
About 75 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mrs. Davis is a 72-year-old woman with atrial fibrillation, off her anticoagulant for two weeks, who presents with sudden right-sided weakness, facial droop, and difficulty speaking that began exactly 75 minutes ago.
She suddenly dropped her coffee cup, slurred her words, and lost the ability to move her right arm and leg while eating breakfast. She is alert and understands questions, but can only produce garbled single words, and she is frightened about permanent brain damage.
She has atrial fibrillation but stopped her anticoagulant two weeks ago because of cost, along with type 2 diabetes and hypertension. She takes metformin and amlodipine and is a retired non-smoker.
Her vitals showed a heart rate of 96, irregularly irregular, blood pressure 168 over 92, and oxygen saturation 97% on room air. Point-of-care glucose was 135, ruling out hypoglycemia as a stroke mimic. Her NIH Stroke Scale score is 16. The non-contrast head CT completed within 20 minutes showed no hemorrhage or established infarct, and CT angiography confirmed an acute occlusion of the M1 segment of the left middle cerebral artery.
My leading diagnosis is acute ischemic stroke from an M1 occlusion of the left middle cerebral artery, most likely cardioembolic given her atrial fibrillation and recent anticoagulation lapse. She presents within the window for both thrombolysis and thrombectomy.
I would activate the stroke thrombolysis and thrombectomy pathway immediately, confirming blood pressure is below the treatment threshold and that there is no bleeding contraindication before proceeding, and would simultaneously involve interventional neuroradiology given the confirmed large-vessel occlusion. Blood pressure would be closely monitored throughout.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Anchor everything to the exact time of onset
“Mrs. Davis is a 72-year-old woman with atrial fibrillation, off her anticoagulant for two weeks, who presents with sudden right-sided weakness, facial droop, and difficulty speaking that began exactly 75 minutes ago.”
Why it belongs: In a stroke presentation, the exact time since last known well is the single fact that determines treatment eligibility, so it belongs in the first sentence alongside the deficit.
This is a 72-year-old female with sudden weakness and facial droop.
Mrs. Davis is a 72-year-old woman with atrial fibrillation who presents with sudden right-sided weakness and facial droop that began exactly 75 minutes ago.
Why: Naming the exact time and the cardioembolic risk factor upfront tells the team this is a time-critical stroke code, not a general weakness complaint.
History of present illness
Describe the deficit and the patient's distress
“She suddenly dropped her coffee cup, slurred her words, and lost the ability to move her right arm and leg while eating breakfast. She is alert and understands questions, but can only produce garbled single words, and she is frightened about permanent brain damage.”
Why it belongs: The abrupt onset during a normal activity and the specific deficits support a vascular event, and naming her fear briefly acknowledges the patient without slowing down the urgent history.
She has weakness and can't talk properly.
She has right-sided weakness, facial droop, and expressive aphasia that came on suddenly while she was eating breakfast.
Why: Naming the specific deficits and their sudden onset is more useful than a general description of weakness.
Relevant background
Flag the anticoagulation lapse and other vascular risks
“She has atrial fibrillation but stopped her anticoagulant two weeks ago because of cost, along with type 2 diabetes and hypertension. She takes metformin and amlodipine and is a retired non-smoker.”
Why it belongs: The anticoagulation lapse is the most likely mechanism for a cardioembolic stroke and directly affects bleeding-risk discussions for thrombolysis.
She has AFib and some other medical problems.
She has atrial fibrillation and stopped her anticoagulant two weeks ago, along with type 2 diabetes and hypertension.
Why: Naming the specific lapse in anticoagulation is more clinically actionable than a vague list of comorbidities.
Objective data
Give vitals, the NIHSS score, and the imaging findings
“Her vitals showed a heart rate of 96, irregularly irregular, blood pressure 168 over 92, and oxygen saturation 97% on room air. Point-of-care glucose was 135, ruling out hypoglycemia as a stroke mimic. Her NIH Stroke Scale score is 16. The non-contrast head CT completed within 20 minutes showed no hemorrhage or established infarct, and CT angiography confirmed an acute occlusion of the M1 segment of the left middle cerebral artery.”
Why it belongs: The normal glucose excludes a common mimic, the NIHSS quantifies severity, and the CT results convert a clinical stroke syndrome into a specific, treatable vascular lesion.
Her CT was fine and the scan showed a clot.
Her non-contrast CT showed no hemorrhage, and CT angiography confirmed an M1 occlusion of the left middle cerebral artery.
Why: Naming the specific vessel and segment tells the team exactly what is being treated.
Assessment
Commit to the diagnosis and its likely mechanism
“My leading diagnosis is acute ischemic stroke from an M1 occlusion of the left middle cerebral artery, most likely cardioembolic given her atrial fibrillation and recent anticoagulation lapse. She presents within the window for both thrombolysis and thrombectomy.”
Why it belongs: The assessment names the vessel, the likely mechanism, and states the time window without yet committing to a specific drug or dose.
This is a stroke, probably from her AFib.
My leading diagnosis is acute ischemic stroke from an M1 occlusion, most likely cardioembolic given her atrial fibrillation and anticoagulation lapse.
Why: Naming the specific vessel and mechanism is more useful to the stroke team than a general statement.
Plan
State the time-critical priorities and remaining checks
“I would activate the stroke thrombolysis and thrombectomy pathway immediately, confirming blood pressure is below the treatment threshold and that there is no bleeding contraindication before proceeding, and would simultaneously involve interventional neuroradiology given the confirmed large-vessel occlusion. Blood pressure would be closely monitored throughout.”
Why it belongs: The plan states the two time-critical treatments and the safety checks that must happen in parallel, without inventing a coagulation panel the source does not provide.
I'll give tPA and call the stroke team.
I would activate the thrombolysis and thrombectomy pathway together, confirming blood pressure and bleeding contraindications first.
Why: Naming both time-critical treatments and the safety checks is more complete than naming one drug alone.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Coagulation studies and exact anticoagulant history
Say: “Her INR and other coagulation studies are not documented in this simulation, so bleeding risk still needs direct confirmation before thrombolysis proceeds.”
Thrombolysis eligibility cannot be finalized without knowing her current coagulation status.
Weight and full medication reconciliation
Say: “Her exact weight is not given, and weight-based thrombolytic dosing still needs to be confirmed.”
Dosing should not be estimated from appearance alone.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Sudden right-sided weakness, facial droop, and aphasia starting exactly 75 minutes ago | Lead | The exact time of onset and the deficit define the entire management pathway. |
| Stopped her anticoagulant two weeks ago because of cost | Lead | This is the most likely mechanism and directly affects the bleeding-risk discussion. |
| Retired teacher, non-smoker | Omit | Occupation does not change the acute stroke pathway. |
| Type 2 diabetes and hypertension | Include | These are additional vascular risk factors relevant to secondary prevention, though secondary to the immediate time-critical decision. |
| NIHSS score of 16 and confirmed M1 occlusion | Lead | These findings quantify severity and confirm eligibility for both thrombolysis and thrombectomy. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
What is her exact eligibility window?
She is 75 minutes from a clear last-known-well time, which is well within the thrombolysis window and the extended thrombectomy window for a confirmed large-vessel occlusion; exact eligibility still requires confirming blood pressure and the absence of bleeding contraindications.
Why check glucose before treating a stroke?
Hypoglycemia can cause focal neurologic deficits that mimic a stroke, so a normal glucose of 135 helps confirm this is a true vascular event rather than a metabolic mimic.
What is still missing before you finalize treatment?
Coagulation studies, her exact weight, and a complete medication reconciliation are not in this simulation, and all affect thrombolysis dosing and safety.
Self-check
A 30-second check before you present
- State the exact time of onset in the opening sentence.
- Name the specific deficits rather than 'generalized weakness.'
- Flag any anticoagulation lapse or bleeding-risk history explicitly.
- Report vitals, the NIHSS score, and glucose before the imaging findings.
- Name the specific vessel and segment from the imaging.
- State the likely mechanism, not just 'stroke.'
- Activate both thrombolysis and thrombectomy pathways when a large-vessel occlusion is confirmed.
- State what coagulation or dosing information is still needed.
Common presentation problems
Repair the habits that make a case hard to follow
Burying the exact time of onset in the middle of the history
Repair: State the exact time in the first sentence, since it determines the entire pathway.
Saying only 'weakness and confusion' instead of the specific deficits
Repair: Name the side, the facial droop, and the type of speech difficulty.
Omitting the anticoagulation lapse
Repair: State it explicitly, since it explains the likely mechanism and affects bleeding-risk discussion.
Naming a specific thrombolytic dose without confirming weight and contraindications
Repair: State that weight and coagulation status still need confirmation before dosing.
Frequently asked questions
Oral case presentation questions
Should I state the NIHSS subscores individually?
Usually the total score is enough for the opening assessment; be ready to give the individual domains if asked, since they help localize the deficit.
Do I need to name the exact thrombolytic agent and dose?
State that thrombolysis is being activated and that dosing will be weight-based and contraindication-checked; a specific dose is only appropriate once those checks are complete.
How long should a stroke-code presentation be?
This worked example targets about 75 seconds. A true code stroke may require an even faster initial statement of time and deficit, with details filling in as the team assembles.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case em_004. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic StrokeAmerican Heart Association / American Stroke Association · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: