What is a physical and neurological exam?
The first step in the diagnosis and treatment of a suspected stroke is a simple examination to evaluate your symptoms and general health. Your symptoms can provide clues about the cause, location, and size of the stroke; your general health may influence what tests and treatments you should receive.
The basic stroke examination can be started by an emergency medical technician (EMT) in the ambulance on the way to the hospital, and continues with your doctor when you arrive at the emergency room.1, 2 A typical examination for suspected stroke consists of:
- A physical examination: The physical exam’s most important components are your vital signs, your appearance, and your mental status, all of which indicate if you have had a stroke and if you are stable enough to get a CT scan.
- A medical history: Your medical history catalogues your stroke symptoms and when they appeared and any other medical conditions you have. How long ago your symptoms started is part of determining whether you are eligible for first-choice treatment with tPA within 3 hours;2 other medical conditions may have contributed to your stroke or affect your stroke treatment options.
- A neurological examination: The neurological exam is a series of questions and physical and mental tests that evaluate how your nervous system (including the brain) is working. By testing these functions, the doctor can establish if and how your brain has been affected by a stroke and determine which diagnostic tests are necessary.
What does the physical examination for stroke consist of?
EMTs will do a quick evaluation for symptoms of stroke before you get to the hospital, looking for slurred speech and any weakness in the face, arm, or leg on one side of the body. The examination will continue once you arrive at the hospital’s emergency room.2 The doctor will check your pulse, temperature, and blood pressure. Your eyes will be examined for blood spots, a sign of bleeding. Using a stethoscope, the doctor will listen for an abnormal rhythm in your heart (atrial fibrillation) that can cause blood clots and for an abnormal whooshing sound in your neck (carotid bruit), a sign that plaque ( atherosclerosis, or hardening of the arteries) is interfering with blood flow to the brain. The doctor will also listen to your lungs and bowels for other abnormal sounds.
What do the results mean?
The most important question answered by the physical exam is if you are stable enough—meaning your medical condition is not rapidly changing—to have a CT scan to rule out bleeding (hemorrhage) in the brain, particularly if you have a severe headache or other signs of a bleeding stroke.
Additional imaging tests may be ordered if the physical exam shows you have certain conditions, such as a carotid bruit or atrial fibrillation. If you have a carotid bruit, the tests may include a carotid Doppler ultrasound or MRA to determine the amount of narrowing or blockage in your carotid arteries. If your doctor hears an irregular heart rhythm, he or she will order an ECG to examine your heart’s rhythm more closely.
The physical exam and other blood tests can also diagnose other conditions, such as high blood pressure, that may affect your stroke treatment.
What is a medical history?
A medical history is a detailed timeline of your stroke symptoms and when you (or a witness) first noticed them, as well as a catalogue of past illnesses, current health conditions, and medications.
The time your symptoms started is important to determine if you are eligible for the first-choice treatment of tPA. To establish when your symptoms first began, you will be asked when you last felt normal and free of symptoms. If you are unable to communicate this to the doctor, a witness may be asked about the last time you looked or sounded normal. Strokes often occur during sleep; if you woke up with stroke symptoms, your stroke onset will be estimated at the last time you were awake and felt normal.
You will also be asked about other medical conditions you have, illnesses or operations you have had in the past, and other stroke risk factors such as a family history of stroke. You will need to provide a list of any medications you are allergic to and all the prescription and over-the-counter medications you are taking, especially any blood thinners (Coumadin, aspirin, clopidogrel) or high blood pressure medications.
How does my medical history affect my stroke diagnosis and treatment?
The most important information provided by the medical history is the time when your stroke symptoms began. If your symptoms started more than 3 hours ago, you may not be eligible for treatment with tPA. Your medical history will also provide valuable information about any allergies you may have to clot-busting and blood thinning drugs used in the emergency treatment of stroke.
A medical history also provides useful information about other medical conditions that may be related to your current symptoms and affect your chances of recovery. These include heart failure and risk factors such as high blood pressure, high cholesterol, and diabetes. These conditions need to be treated and controlled to reduce the chances of complications during treatment and improve your ability to recover from a stroke.
Some illnesses—such as diabetes, seizures, and migraines—can make it look like you are having a stroke by mimicking stroke symptoms, such as weakness on one side of the body, speech problems, and vision changes. If your doctor suspects something other than stroke may be causing your symptoms, he or she will order tests to identify them, such as an EEG to detect seizures, a glucose test to measure the amount of sugar in your blood, and an MRI if migraines are suspected. Ruling out other possible causes of stroke symptoms ensures you receive the right diagnosis and can be treated quickly.
What does the neurological exam for stroke consist of?
A neurological examination for stroke evaluates your level of awareness and brain function. Different parts of the brain control different functions like language, speech, vision, eye movement, muscle control, and sense of touch. Each section of the exam tests a different function of the brain.
Using the information from your medical history and physical exam, the doctor will ask you a series of questions and give you a few physical and mental tasks to determine which areas of your brain have been affected by stroke and how severely. Your responses will be measured using a stroke scale, usually the National Institutes of Health Stroke Scale (NIHSS) see below for more.
The doctor will test your level of awareness and alertness by asking you your name, the current date, and to open and close your eyes. Your language and comprehension will be assessed by having you repeat a short list of words and describe a picture.
Other tasks test key nerves in the brain that control movement, vision, muscle strength, and sensation. The doctor will check your face to see if one side of your mouth or one of your eyelids is drooping. You will be checked for loss of vision and abnormal eye movement. Your muscle strength and coordination will be evaluated by holding your arms and legs out to see if one of them drifts down or cannot be lifted, and by touching your nose with your right index finger.
You may also be lightly pricked with a sharp pin first and then touched with something blunter to see if you can feel the difference. Different areas of your body, including your arms, legs, and face, will be tested to see if you have lost feeling on one side.
What is the NIHSS Stroke Scale?
The neurological examination is scored using the National Institutes of Health Stroke Scale (NIHSS). The NIHSS is an evaluation tool that measures how your brain has been affected by stroke. On this test, a score of zero indicates you are completely normal; the higher your score, the more severe your stroke was.3
| Stroke Severity | NIHSS Stroke Score |
| Normal | 0 |
| Mild | Less than 5 |
| Moderate | 5 to 15 |
| Severe | 15 to 25 |
| Very Severe | More than 25 |
The following table shows some of the questions you may be asked during a neurological examination and how they affect your stroke score. The test takes 5 to 10 minutes to perform.
| Stroke Scale Sample Questions | |
| Question | Score |
| Is the patient alert? | No +3 points |
| How old is the patient? What is the current month? | One correct +1 point Neither correct +2 points |
| Can patient open and close eyes, grip and release hand? | One +1 point Neither +2 points |
| Are both eyes looking in the same direction? | No +2 points |
| Is there loss of vision? | No vision +3 points Partial Loss +1 point |
| Does face move evenly on both sides when smiling? | Minor paralysis +1 points Complete paralysis +3 points |
| Does arm drift downward 10 seconds after extending? | Yes +1-4 points |
| Does leg drift downward 5 seconds after extending? | Yes +1-4 points |
| Is there loss of coordination when touching heels to shins on both legs? | One leg +1 point Both legs +2 points |
| Does patient feel pain when pricked with a pin? | Some pain +1 point No feeling +2 points |
| Describe what is happening in the picture | Unable to speak +3 points Very limited speech +2 points |
| Read from a list/repeat a sentence | Severely slurred speech +2 points Slurs some words +1 points |
What do the results mean?
The neurological exam shows how the stroke has affected your mental and physical abilities. Loss of an ability indicates where in the brain the stroke may have occurred and how much damage was done.
One of the first clues to the location of a stroke is whether or not both sides of your body are working equally well. The right side of your brain controls the left side of your body, and the left side of your brain controls the right side of your body. If you have weakness or paralysis on only one side of your body, the doctor will know that the stroke occurred in the opposite side of your brain. Paralysis on both sides of the body may indicate that the stroke occurred in the base of the brain (the brain stem); all signals traveling from the brain to the body must pass through the brain stem.
Changes in specific mental abilities, such as understanding or talking, can also help doctors get a better idea of the location of the stroke, since these skills are controlled by particular areas of the brain. Further screening with imaging tests such as MRI and angiography can confirm the exact location of the stroke.
The neurological exam also provides a score that indicates how severely your mental and physical abilities have been affected by stroke. This score enables doctors to estimate your chances of recovery and determine the best treatment for your type of stroke. A high score means you have had a severe stroke and may take longer to recover or may not recover completely.
