NIH stroke scale Questions with Answers (All Answers Correct)

1a LOC - 0: alert 1: not alert; aroused with minor verbal stimulation 2: not alert; requires strong or painful stimulation 3: reflex movements only or totally unresponsive 1b LOC questions - What month is it? What's your age? 0: answers both questions correctly 1: answers one question 2: answers neither question correctly 1c LOC COMMANDS - -close your eyes, now open -make a fist with your hand (can show pt to make a fist) Give credit if attempt is made but not completed do to weakness 0: both tasks performed correctly 1: performs one task correctly 2: neither task is performed correctly 2 BEST GAZE - -have pt track your finger/examiners face 0: normal (if pt has strabismus but eye leaves midline and looks r and l, then normal) 1: partial gaze palsy (if there's conjugate deviation of eyes that can be overcome by voluntary or reflexive activity, abducens palsy) 2: forced deviation (not overcome by the oculocephalic maneuver) 3 VISUAL FIELDS - -tell pt you'll be testing peripheral vision and to look at your nose -have pt count number of fingers you're holding up in all 4 quadrants -cover R eye, ask pt how many fingers they see in all 4 quadrants -cover L eye, repeat 0: no visual loss (if pt confused but looks at fingers, score 0)1: partial hemianopia (patient recognizes no visual stimulus in ONE specific quadrant) 2: complete hemianopia (patient recognizes no visual stimulus in ONE HALF of the visual field 3: bilateral hemianopia (blind including cortical blindness) 4 FACIAL PALSY - -encourage pt to show teeth -raise eyebrows -squeeze eyes shut -for pt not following commands, look at grimace with noxious stimuli 0: normal 1: minor paralysis 2: partial paralysis (paralysis of lower face) 3: complete paralysis 5 MOTOR ARM - - extend arms 90 degrees if pt is sitting or 45 degrees if pt is supine, palms must be down, one arm at a time -count 10 seconds with release of a limb 0: no drift or no drift after initial dip for 10 sec 1: drift before full 10 sec 2: some effort against gravity but arm cannot maintain proper position and drifts down 3: arm falls, no effort against gravity 4: no voluntary movement (any movement at all like shoulder shrug will lower score to 3) if pt unresponsive, automatically a 4