Physical Examination for Suspected Stroke - Charting Format
Document a rapid, systematic neurological examination using the National Institutes of Health Stroke Scale (NIHSS) as the standardized framework for all suspected stroke patients 1, 2.
Initial Assessment (ABC Priority)
Vital Signs:
- Airway, breathing, circulation status 1, 2
- Blood pressure (both arms if asymmetry suspected)
- Heart rate and rhythm
- Temperature
- Oxygen saturation
- Respiratory rate
General Appearance:
- Level of consciousness (alert/drowsy/obtunded/coma)
- Signs of trauma or seizure activity
- Hydration status
Neurological Examination (NIHSS Components)
1. Level of Consciousness (LOC):
- 1a. Alertness: 0=alert, 1=arousable to minor stimulation, 2=arousable only to pain, 3=unresponsive 3
- 1b. Orientation: Ask age and current month (0=both correct, 1=one correct, 2=neither correct)
- 1c. Commands: Ask to open/close eyes and grip/release hand (0=both correct, 1=one correct, 2=neither correct)
2. Best Gaze (Horizontal Eye Movements):
3. Visual Fields (Confrontation Testing):
- 0=no visual loss, 1=partial hemianopia, 2=complete hemianopia, 3=bilateral hemianopia 3
4. Facial Palsy:
- 0=normal symmetry, 1=minor paralysis (flat nasolabial fold/asymmetric smile), 2=partial paralysis (lower face), 3=complete paralysis (upper and lower face) 4
5. Motor Arm (Test Both Sides):
- Arms outstretched 90° (sitting) or 45° (supine) for 10 seconds
- Left arm: 0=no drift, 1=drift but doesn't hit bed, 2=some antigravity effort, 3=no antigravity effort, 4=no movement 3
- Right arm: (same scoring)
6. Motor Leg (Test Both Sides):
- Raise leg to 30° and hold for 5 seconds
- Left leg: 0=no drift, 1=drift but doesn't hit bed, 2=some antigravity effort, 3=no antigravity effort, 4=no movement 3
- Right leg: (same scoring)
7. Limb Ataxia:
- Finger-to-nose and heel-to-shin testing
- 0=no ataxia, 1=ataxia in 1 limb, 2=ataxia in 2 limbs 4
8. Sensory:
- Test with pinprick or light touch
- 0=normal, 1=mild-moderate unilateral loss, 2=severe or total loss 3
9. Language:
- Assess naming, comprehension, repetition
- 0=normal, 1=mild aphasia, 2=severe aphasia, 3=mute/global aphasia 4
10. Dysarthria:
- Assess speech clarity
- 0=normal articulation, 1=mild-moderate slurring, 2=severe/unintelligible 3
11. Extinction/Inattention:
- Simultaneous bilateral stimulation (tactile and visual)
- 0=normal, 1=extinction to double simultaneous stimulation, 2=profound neglect 3
Cardiovascular Examination
Cardiac:
- Heart rhythm (regular/irregular)
- Murmurs, gallops, rubs
- Signs of heart failure (JVD, peripheral edema) 6, 4
Vascular:
- Carotid pulses (palpate gently, note asymmetry)
- Carotid bruits (auscultate bilaterally) 7
- Peripheral pulses if indicated
Additional Physical Findings
Head/Neck:
- Signs of head trauma
- Nuchal rigidity (if subarachnoid hemorrhage suspected)
Skin:
- Petechiae, purpura, or embolic lesions (Janeway lesions, Osler nodes) 5
Seizure Activity:
- Document any witnessed seizure activity or post-ictal state 2
Documentation Format
Total NIHSS Score: ___ /42
- Score <5 = minor stroke
- Score 5-15 = moderate stroke
- Score 16-20 = moderate-severe stroke
- Score >20 = severe stroke 3
Critical Pitfall: The NIHSS must be performed by trained personnel and should not delay imaging or treatment decisions 1, 2. Document time of examination and examiner name. Repeat NIHSS serially to track clinical evolution.