What is the initial physical exam workup for a suspected stroke patient, including assessment of neurological status using tools such as the National Institutes of Health (NIH) Stroke Scale (NIHSS)?

Physical Examination Workup for Suspected Stroke

The initial physical examination workup for a suspected stroke patient must include a rapid neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine focal neurological deficits and assess stroke severity. 1

Initial Assessment (First Minutes)

1. Airway, Breathing, Circulation (ABC) Assessment

   • Ensure patent airway and adequate oxygenation 2
   • Provide supplemental oxygen to maintain oxygen saturation ≥94% 2
   • Correct hypotension and hypovolemia to maintain systemic perfusion 2

2. Vital Signs Measurement

   • Heart rate and rhythm
   • Blood pressure (critical for thrombolysis decisions)
   • Temperature
   • Oxygen saturation
   • Hydration status
   • Presence of seizure activity 2

Neurological Examination Using NIHSS

The NIHSS is the standardized stroke assessment tool that should be completed within 5-8 minutes 3. It includes:

Component	Assessment	Score Range
Level of consciousness	Alertness	0-3
Orientation questions	Month and age	0-2
Response to commands	Open/close eyes, grip/release	0-2
Gaze	Horizontal eye movements	0-2
Visual fields	Visual field testing	0-3
Facial movement	Facial palsy	0-3
Motor function (arms)	Drift testing	0-4 each arm
Motor function (legs)	Drift testing	0-4 each leg
Limb ataxia	Finger-nose, heel-shin tests	0-2
Sensory	Pin prick response	0-2
Language	Naming, repetition, comprehension	0-3
Articulation	Speech clarity	0-2
Extinction/inattention	Double simultaneous stimulation	0-2
Total NIHSS Score		0-42

1

NIHSS Score Interpretation

• Small stroke: NIHSS <5
• Moderate stroke: NIHSS 5-15
• Large/severe stroke: NIHSS >16 1

Note: The NIHSS may underestimate posterior circulation strokes, which often present with lower scores despite significant deficits 4

Required Laboratory Tests

Immediate blood work should include:

• Electrolytes
• Random glucose (priority test before thrombolysis)
• Complete blood count
• Coagulation status (INR, aPTT)
• Creatinine
• Troponin 2

These tests should not delay imaging or treatment decisions for thrombolysis and endovascular treatment 2.

Immediate Imaging

All patients with suspected acute stroke must undergo immediate brain imaging:

• Non-contrast CT or MRI to differentiate ischemic from hemorrhagic stroke 2
• Consider CT angiography for patients with suspected large vessel occlusion 2

Additional Physical Examination Elements

1. Cardiovascular Examination

   • Check for carotid bruits
   • Assess for arrhythmias
   • Listen for heart murmurs 1

2. Seizure Assessment

   • Monitor for seizure activity
   • New onset seizures should be treated with appropriate short-acting medications if not self-limited 2

Common Pitfalls to Avoid

1. Posterior Circulation Stroke Assessment

   • NIHSS may underestimate severity of posterior circulation strokes
   • Patients with posterior circulation strokes often present with lower NIHSS scores (median 2 vs. 7 for anterior circulation) but may still have poor outcomes 4
   • Consider additional assessment of brainstem functions for suspected posterior circulation strokes 5

2. Time Management

   • Complete evaluation and treatment decisions should occur within 60 minutes of arrival 2
   • Do not delay neuroimaging or treatment decisions while waiting for laboratory results 2

3. Stroke Mimics

   • Consider alternative diagnoses such as seizures, migraine, or hypoglycemia
   • Check blood glucose immediately in all suspected stroke patients 2

By following this systematic approach to the physical examination workup for suspected stroke, clinicians can rapidly assess patients, determine stroke severity, and facilitate timely treatment decisions that directly impact morbidity, mortality, and quality of life outcomes.