HPI Template for a Patient with Stroke-Like Symptoms
The most critical component of the HPI for stroke patients is establishing the exact time of symptom onset, as this directly impacts treatment eligibility and outcomes. 1
Chief Complaint
- Document the patient's primary neurological deficit(s)
- Example: "Right-sided weakness," "Difficulty speaking," "Facial droop"
Time of Onset
- Document exact time when patient was last known to be at baseline/symptom-free
- For wake-up strokes: document when patient was last known to be normal
- Use creative questioning to establish time anchors:
- Phone call timestamps
- Television program times
- Last known normal activity 1
Symptom Characteristics
- Sudden vs. gradual onset
- Progression of symptoms (stable, improving, worsening)
- Any transient symptoms that resolved prior to current presentation
- Associated symptoms (headache, nausea, vomiting, seizures, loss of consciousness)
Risk Factors
Cardiovascular
- Hypertension
- Atrial fibrillation/arrhythmias
- Coronary artery disease/prior MI
- Heart failure
- Peripheral arterial disease
- Carotid stenosis
- Valvular disease 1
Metabolic
- Diabetes mellitus
- Hyperlipidemia
- Obesity 1
Lifestyle
- Tobacco use (current/former, pack-years)
- Alcohol use
- Illicit drug use (particularly cocaine) 1
- Physical inactivity 1
Other
- Prior stroke or TIA
- Family history of stroke
- Hypercoagulable states
- Migraine
- Sleep disorders
- Recent surgery or trauma 1
Medication History
- Anticoagulants (warfarin, DOACs)
- Antiplatelet agents
- Antihypertensives
- Lipid-lowering medications
- Contraceptives
- Over-the-counter medications 1
Review of Systems
Neurological
- Vision changes (diplopia, visual field cuts)
- Speech changes (aphasia, dysarthria)
- Sensory changes (numbness, tingling)
- Balance/coordination problems
- Dizziness/vertigo
- Confusion/altered mental status
Cardiovascular
- Chest pain
- Palpitations
- Shortness of breath
- Edema
Other
- Recent infections
- Headaches
- Seizure activity
- Syncope/presyncope 1
Stroke Mimics Assessment
Document presence/absence of features suggesting stroke mimics:
- Hypoglycemia
- Seizure activity or postictal state
- Migraine with aura
- Conversion disorder
- Hypertensive encephalopathy
- Drug toxicity 1
Functional Status
- Pre-stroke functional status and independence
- Living situation
- Use of assistive devices
- Baseline cognitive function 1
Standardized Assessment
Physical Examination Focus
- Vital signs (BP, HR, temperature, respiratory rate, oxygen saturation)
- General appearance
- Cardiovascular exam (murmurs, arrhythmias, carotid bruits)
- Neurological exam:
- Mental status
- Cranial nerves
- Motor strength
- Sensory function
- Coordination
- Reflexes
- Gait (if able to assess) 1
Initial Diagnostic Considerations
- Ischemic vs. hemorrhagic stroke
- Vascular territory involved
- Potential etiology (cardioembolic, large vessel atherosclerosis, small vessel disease)
- Eligibility for acute interventions (thrombolysis, thrombectomy) 1, 2
Remember that the single most important piece of historical information is the time of symptom onset, as this directly impacts treatment decisions and eligibility for time-sensitive interventions like thrombolysis and thrombectomy 1. A standardized approach using validated stroke scales like the NIHSS helps quantify deficits and facilitates communication among healthcare providers 1, 2.