What is the approach to a patient with a past history of stroke, including history taking and physical examination?

Approach to a Patient with Past History of Stroke

When evaluating a patient with a prior stroke, immediately establish the time they were last known well, obtain focused vascular risk factor history, perform the NIH Stroke Scale (NIHSS) for neurological assessment, and measure blood pressure—these are the critical elements that determine acute management decisions and risk stratification. 1

History Taking

Time-Critical Information

• Document the exact time the patient was last at baseline or symptom-free 1
  • For patients who awaken with symptoms, the time last known well is when they were last awake and symptom-free 1
  • Use creative questioning with time anchors: check cell phone call timestamps or television programming times to establish onset 1
  • Ask if anyone witnessed symptom onset and obtain their contact information 1

Essential Vascular Risk Factors

• Cardiovascular disease history: myocardial infarction, angina, cardiac arrhythmias (especially atrial fibrillation), congestive heart failure, valvular surgery, pacemaker, peripheral arterial disease 1
• Cerebrovascular history: prior stroke or transient ischemic attack (TIA), carotid endarterectomy 1
• Metabolic conditions: diabetes mellitus, hypertension, hyperlipidemia 1
• Other risk factors: seizure history, trauma related to current event, smoking, alcohol use 1

Medication History

• Current anticoagulation therapy with warfarin or other anticoagulants is critical for determining thrombolytic eligibility 1
• Document all current medications including over-the-counter preparations 1, 2
• Inquire about recent heparin use 1

Family History

• First-degree relatives with stroke, vascular disease, myocardial infarction, dementia, or other neurological diseases 1
• Document age at death and age when events occurred 1

Physical Examination

Vital Signs and Initial Assessment

• Blood pressure measurement is critical 1
  • Hypertension is common in acute ischemic stroke patients 1
  • Transient blood pressure elevation may represent compensatory response to enhance collateral flow 1
  • Measure orthostatic blood pressure 1
• Temperature, heart rate, respiratory rate, oxygen saturation 1, 3
• Height, weight, waist circumference, ankle-brachial index 1

Neurological Examination Using NIHSS

• The NIH Stroke Scale (NIHSS) is the standard for measuring stroke severity and functional improvement 1
  • It is a valid, efficient, and reliable measure of neurological status 1
  • Formal training and certification in the scale are recommended for reliability 1
  • Use it to monitor changes in neurological status over time, both in hospital and during follow-up 1
  • The NIHSS score provides prognostic information and influences acute treatment decisions 1

Focused Neurological Assessment

• Level of consciousness: Most patients are alert, but decreased consciousness occurs with major hemispheric infarctions, basilar artery occlusion, or cerebellar strokes with brain stem compression 1
• Focal neurological deficits: weakness (especially unilateral), numbness, speech disturbance 4
• Cranial nerve examination, motor movements, reflexes, Babinski signs 1
• Gait assessment (timed gait if possible) 1
• Vision and hearing 1

Associated Symptoms

• Headache occurs in approximately 25% of stroke cases 1
• Nausea and vomiting can occur with brain stem or cerebellar strokes 1

Ruling Out Stroke Mimics

Common conditions that mimic stroke must be excluded quickly: 1

• Postseizure state (Todd's paralysis): presents with unilateral weakness 1
• Brain neoplasm: can cause stroke-like deterioration 1
• Migraine with aura: may be confused with TIA or stroke 1
• Hypoglycemia: check blood glucose immediately 1, 3
• Seizures: obtain history of witnessed seizure activity 1
• Psychogenic: look for lack of objective cranial nerve findings, neurological findings in nonvascular distribution, inconsistent examination 1

Critical Pitfalls to Avoid

• Do not delay thrombolytic therapy waiting for laboratory results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or the patient has received heparin/warfarin 1
• Do not treat elevated blood pressure aggressively unless diastolic BP >120 mmHg or systolic BP >220 mmHg in non-thrombolytic candidates, as elevation may be compensatory 1
• Do not assume "altered mental status" alone indicates stroke—this presentation is more likely a stroke-mimic 5
• Do not overlook atrial fibrillation—it is a critical risk factor and can be detected acutely 1, 5

Additional Assessments

Functional and Cognitive Status

• Behavioral assessment using tools like the Neuropsychiatric Inventory-Q 1
• Depression screening with scales such as CES-D or Geriatric Depression Scale 1
• Functional assessment using Pfeffer Functional Assessment Questionnaire or Barthel Index 1

Cardiovascular Evaluation

• 12-lead ECG should be performed due to high incidence of cardiac disease in stroke patients 1, 3
• Cardiac enzyme tests to screen for myocardial ischemia 1