What is the initial physical exam workup for a patient presenting with possible stroke symptoms?

Initial Physical Examination Workup for Possible Stroke

The initial physical examination workup for a patient presenting with possible stroke symptoms should include a rapid assessment of airway, breathing, and circulation, followed by a standardized neurological examination using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS), and assessment of vital signs including heart rate, rhythm, blood pressure, temperature, and oxygen saturation.1

Primary Assessment

1. Airway, Breathing, Circulation (ABC) Assessment 1

   • Ensure patent airway
   • Assess respiratory rate and pattern
   • Check circulatory status (pulse, blood pressure)

2. Standardized Neurological Examination 1, 2

   • Use a validated stroke scale (NIHSS or Canadian Neurological Scale)
   • Assess for focal neurological deficits:
     • Motor function: Unilateral weakness of face, arm, and/or leg
     • Speech: Aphasia, dysarthria
     • Sensory function: Hemibody sensory loss
     • Visual fields: Hemianopia, monocular vision loss
     • Coordination: Ataxia
     • Cranial nerves: Diplopia, facial droop

3. Vital Signs Assessment 1

   • Heart rate and rhythm
   • Blood pressure (critical for treatment decisions)
   • Temperature
   • Oxygen saturation
   • Hydration status

Secondary Assessment

1. Seizure Assessment 1

   • Evaluate for seizure activity
   • Document any seizures occurring at onset or within 24 hours of symptoms

2. Swallowing Assessment 1

   • Perform swallowing screen using a validated tool
   • Keep patient NPO until swallowing screen completed
   • Consider alternative medication routes if swallowing is impaired

3. Risk Stratification 1, 2

   • Determine time of symptom onset (critical for treatment decisions)
   • Identify high-risk features:
     • Unilateral weakness (face, arm, leg)
     • Speech disturbance/aphasia
     • Symptoms within last 48 hours (highest risk)

Laboratory and Diagnostic Workup

1. Immediate Blood Work 1

   • Electrolytes
   • Random glucose
   • Complete blood count
   • Coagulation status (INR, aPTT)
   • Creatinine and eGFR
   • Troponin

2. Cardiac Assessment 1, 2

   • ECG (can be deferred until after acute treatment decisions if patient is hemodynamically stable)

3. Imaging 1, 2

   • Brain imaging (CT or MRI) should be completed as soon as possible
   • Vascular imaging (CTA or MRA) from aortic arch to vertex for suspected stroke
   • MRI with DWI is preferred for TIA evaluation due to higher sensitivity

Important Clinical Considerations

1. Time-Critical Nature

   • Do not delay imaging or treatment decisions while waiting for laboratory results 1
   • "Time is brain" - rapid assessment is critical for treatment eligibility

2. Blood Pressure Management 1

   • Monitor blood pressure closely
   • For patients not eligible for thrombolysis: consider treatment only if systolic >220 mmHg or diastolic >120 mmHg
   • For thrombolysis candidates: blood pressure must be <185/110 mmHg

3. Common Pitfalls to Avoid

   • Missing atypical presentations: Patients with "non-traditional" symptoms (altered mental status, dizziness, generalized weakness) are more likely to have stroke diagnosis missed 3
   • Delaying assessment: Chest X-ray and ECG should not delay stroke evaluation unless patient is hemodynamically unstable 1
   • Failing to recognize TIA: Patients with resolved symptoms still require urgent evaluation 1, 2

4. Stroke Mimics

   • Consider other diagnoses that may present with stroke-like symptoms
   • Up to 19% of patients initially diagnosed with stroke have other acute conditions requiring specific treatment 4

By following this systematic approach to the physical examination workup for possible stroke, clinicians can rapidly identify patients with stroke, determine eligibility for time-sensitive treatments, and improve patient outcomes.