IM18.3-7 | Stroke Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

The clinical evaluation of a stroke patient integrates three skills: history-taking (anchored on last-known-well time, deficit characterisation, contraindications to thrombolysis), neurological examination (NIHSS-structured: consciousness, gaze, visual fields, facial palsy, motor, coordination, sensation, language, dysarthria, neglect), and lesion localisation.

Localisation principles:
- UMN lesion (Babinski sign persists even in acute flaccidity): supra-anterior horn cell
- Left hemisphere stroke: right hemiplegia + aphasia (Broca's = non-fluent, comprehension intact; Wernicke's = fluent, paraphasic, comprehension impaired; Global = all language impaired, large MCA territory)
- Right hemisphere stroke: left hemiplegia + neglect/anosognosia (often underestimated)
- Internal capsule: dense equal face/arm/leg hemiplegia WITHOUT cortical signs
- Brainstem: crossed signs (ipsilateral CN palsy + contralateral body)
- Cerebellum: ipsilateral ataxia, NO hemiplegia

Speech/language distinction:
- Aphasia = language disorder (content, comprehension, naming, repetition impaired) — left hemisphere
- Dysarthria = articulation disorder (language content intact) — corticobulbar/cerebellar/bulbar

Bladder dysfunction: UMN lesion (stroke) = uninhibited bladder → urge incontinence; LMN/sacral = flaccid bladder → retention.

Documentation must include: last-known-well time, NIHSS score, localisation statement, BP, blood glucose, contraindication check, and time stamps for CT ordering.

REFLECT

Return to the hook patient — the 68-year-old woman who produces only unintelligible sounds but nods to show she understands you. You now know she has Broca's (expressive) aphasia, not Wernicke's, because her comprehension is preserved. You know her last-known-well time is 08:10 am (breakfast) and arrival time is 09:43 am — 1 hour 33 minutes within the thrombolysis window. You can estimate her NIHSS from what you have observed: language 2–3, facial palsy 1–2, arm motor 3. You have enough information, without words from the patient, to make the critical decision and communicate it to the family.

Reflect on this: what additional question would you have asked in the first 30 seconds before examining her — the one question whose answer would change everything if positive? (Answer: 'Is she on any blood thinners?') And how would you explain to her daughter, who is asking 'Can she hear us? Does she understand us?' — how would you answer that question truthfully and compassionately, using what you now know about Broca's aphasia?