Announcements: Neuromuscular section updated with more questions.

  • Right or left handed?
  • Onset sudden or gradual?
  • Symptoms at onset and progression in time
  • Symptoms fluctuating? 
  • Had these symptoms in the past?
  • Time of onset? If not witnessed, then last seen normal? If awoke with symptoms, what time were they last awake with no symptoms?
  • Associated symptoms: headache / neck pain, alteration of consciousness, abnormal movements
  • Is the patient on antiplateles / anticoagulation?
  • Stroke risk factors: HTN, HL, DM, CAD, smoker, illicit drug use, personal or family history of hypercoagulable states, cardiac arrhythmias, cardiomyopathy, history of migraines, prior stroke /TIA

EXAM:  full physical and neurologic exam paying attention to BP and fingerstick, cardiac and carotid exam, new or old focal deficits, perform and document NIHSS

WORKUP in the ED: Non-contrast head CT, labs: PT/PTT/INR, CBC, BMP, urine: UA, urine tox, CXR, EKG, Consider CTA neck to Circle of Willis (COW)


  • Admit to neurology; neurochecks, vital sign parameters
  • Initiate antiplatelet agent
  • MRI brain w/wo with MRA
  • TTE with bubble study
  • Carotid Doppler if no CTA obtained
  • Telemetry AND 24-hour Holter monitor
  • PT/OT
  • AM labs: lipid panel, HgbA1c, ESR/CRP, TSH/T4, cardiac enzymes, homocysteine, fasting glucose
  • May consider permissive hypertension if blood pressure dependent exam and flow limiting lesion seen on vascular imaging; hold antihypertensives and halve beta-blocker dose
  • 3 oz bedside swallow eval
  • Fingersticks QID-AC and RISS
  • Neurosurgery consult if large hemispheric or posterior fossa infarct
  • Bowel regimen
  • DVT ppx: heparin/venodynes
  • Code status

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