Makindo Medical Notes"One small step for man, one large step for Makindo" |
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Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Atrial Fibrillation |Atrial Myxoma |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Cardioembolic stroke |CT Basics for Stroke |Endocarditis and Stroke |Haemorrhagic Stroke |Stroke Thrombolysis |Hyperacute Stroke Care
Stroke Assessment - The aim of this assessment tool is to help enable medical and nursing staff to differentiate patients with stroke and stroke mimics. If BM < 3.5 mmol/l treat urgently and reassess once blood glucose normal | YES | NO |
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Has there been loss of consciousness or syncope? | -1 | 0 |
Has there been seizure activity? | -1 | 0 |
Is there a NEW ACUTE onset (or on awakening from sleep)? | ||
Asymmetric facial weakness | +1 | 0 |
Asymmetric arm weakness | +1 | 0 |
Asymmetric leg weakness | +1 | 0 |
Speech disturbance | +1 | 0 |
Visual field defect | +1 | 0 |
If Score = 1 or more then treat as possible stroke and do further assessment | TOTAL |
Category | Description | Score |
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1a. Level of Consciousness | Alert, responsive to stimuli | 0 = Alert, responsive
1 = Drowsy 2 = Obtunded 3 = Coma/unresponsive |
1b. LOC Questions | Asks the patient their age and the current month | 0 = Both correct
1 = One correct 2 = Neither correct |
1c. LOC Commands | Patient performs simple tasks (e.g., open/close eyes, make a fist) | 0 = Both correct
1 = One correct 2 = Neither correct |
2. Best Gaze | Tests horizontal eye movements | 0 = Normal
1 = Partial gaze palsy 2 = Forced deviation |
3. Visual Fields | Test each eye separately | 0 = No visual loss
1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral blindness |
4. Facial Palsy | Facial movement symmetry | 0 = Normal
1 = Minor paralysis 2 = Partial paralysis 3 = Complete paralysis |
5. Motor Function - Arm | Hold arms up for 10 seconds | 0 = No drift
1 = Drift 2 = Some effort against gravity 3 = No effort against gravity 4 = No movement |
6. Motor Function - Leg | Hold leg up for 5 seconds | 0 = No drift
1 = Drift 2 = Some effort against gravity 3 = No effort against gravity 4 = No movement |
7. Limb Ataxia | Finger-to-nose and heel-to-shin tests | 0 = Absent
1 = Present in one limb 2 = Present in two limbs |
8. Sensory | Pinprick sensation test | 0 = Normal
1 = Mild/moderate loss 2 = Severe loss/no response |
9. Best Language | Assess patient’s ability to describe, name objects, and read sentences | 0 = No aphasia
1 = Mild aphasia 2 = Severe aphasia 3 = Mute/global aphasia |
10. Dysarthria | Slurred speech | 0 = Normal articulation
1 = Mild/moderate dysarthria 2 = Severe dysarthria (unintelligible or mute) |
11. Extinction and Inattention (Neglect) | Tests for neglect (visual, auditory, or tactile) | 0 = No neglect
1 = Mild neglect 2 = Severe neglect |