The clinical bedside evaluation of stroke patients is a vital part of the workup. A detailed history and physical exam is necessary, as localization, etiology, and comorbidities need to be quickly assessed. The history and physical is vital and is the best way to diagnose stroke imitators. It is important to emphasize that in the acute setting, when a patient is still in the window for tPA, certain aspects of the history and physical examination will have to be abbreviated and focused so as not to delay necessary therapy. Firstly, it is important to establish time of onset of symptoms when you first meet the patient. If the patient is unable to communicate, you will have to find out this information from actual witnesses of the event. It is critical that no assumptions are made about time of onset based on the time EMS was called. Often family or friends may not seek help until a significant amount of time has elapsed. Of note, if a patient wakes up with stroke symptoms, the accepted time of onset is the last time the patient was seen at his/her baseline. The second thing to determine in your initial assessment is the patient’s National Institutes of Health stroke scale (NIHSS). Although the NIHSS has many limitations, it is our best tool for initially assessing a patient having an acute stroke. You will do well to find out from the patient or from family which deficits are new and which are baseline for the patient. As you do the NIHSS pay attention to the constellation of deficits and try to determine whether most of the deficits can be attributed to blockage of bloodflow to a particular vascular territory. Given the importance of brain imaging in the acute setting it is reasonable to postpone parts of your evaluation until after some initial imaging (head CT without contrast or a hyperacute MRI scan) is obtained.
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