APEX NIH STROKE SCALE (NIHSS) CERTIFICATION
Complete Patient Scenarios 1-6 (2026/2027 Edition)
PATIENT 1
Patient Scenario: A 67-year-old right-handed male presents to the ED 2 hours after symptom
onset. He is awake and alert but confused. He is unable to state his age or the current month
correctly. He follows both commands to open/close eyes and make a fist without difficulty. He
has full visual fields, no gaze preference, and no facial asymmetry. Motor testing shows 5/5
strength throughout. No ataxia, sensory intact. Speech is fluent but with occasional paraphasic
errors. No extinction.
Table
Item Score Rationale
Patient is awake and alert (responsive). LOC is scored
1a. Level of based on responsiveness, not orientation. Confusion is
Consciousness 0 assessed in 1b, not 1a.
Unable to state age or current month correctly—answers
1b. LOC Questions 2 neither correctly.
Follows both commands (open/close eyes, make fist)
1c. LOC Commands 0 without difficulty.
2. Best Gaze 0 No gaze preference or palsy noted.
3. Visual Fields 0 Visual fields are intact.
4. Facial Palsy 0 No facial asymmetry noted.
, Item Score Rationale
5. Motor Arm (Left) 0 5/5 strength, no drift.
5. Motor Arm (Right) 0 5/5 strength, no drift.
6. Motor Leg (Left) 0 5/5 strength, no drift.
6. Motor Leg (Right) 0 5/5 strength, no drift.
7. Limb Ataxia 0 No ataxia present.
8. Sensory 0 Sensory intact.
Fluent speech with occasional paraphasic errors. Mild-
9. Best Language 1 to-moderate aphasia.
10. Dysarthria 0 Speech is fluent, no dysarthria noted.
11.
Extinction/Inattention 0 No extinction or inattention.
TOTAL NIHSS SCORE: 3
Clinical Interpretation: Mild stroke with isolated cognitive-linguistic deficits. This pattern
suggests a left hemisphere cortical lesion, likely involving posterior language areas (posterior
temporal/parietal region) without motor involvement.
PATIENT 2
Patient Scenario: A 72-year-old left-handed female presents 45 minutes after symptom onset.
She is drowsy but opens her eyes when called loudly. She answers her age correctly but not the
current month. She performs one command correctly (opens eyes) but cannot make a fist with
the other hand. She has rightward gaze preference that corrects with oculocephalic maneuver.
Complete Patient Scenarios 1-6 (2026/2027 Edition)
PATIENT 1
Patient Scenario: A 67-year-old right-handed male presents to the ED 2 hours after symptom
onset. He is awake and alert but confused. He is unable to state his age or the current month
correctly. He follows both commands to open/close eyes and make a fist without difficulty. He
has full visual fields, no gaze preference, and no facial asymmetry. Motor testing shows 5/5
strength throughout. No ataxia, sensory intact. Speech is fluent but with occasional paraphasic
errors. No extinction.
Table
Item Score Rationale
Patient is awake and alert (responsive). LOC is scored
1a. Level of based on responsiveness, not orientation. Confusion is
Consciousness 0 assessed in 1b, not 1a.
Unable to state age or current month correctly—answers
1b. LOC Questions 2 neither correctly.
Follows both commands (open/close eyes, make fist)
1c. LOC Commands 0 without difficulty.
2. Best Gaze 0 No gaze preference or palsy noted.
3. Visual Fields 0 Visual fields are intact.
4. Facial Palsy 0 No facial asymmetry noted.
, Item Score Rationale
5. Motor Arm (Left) 0 5/5 strength, no drift.
5. Motor Arm (Right) 0 5/5 strength, no drift.
6. Motor Leg (Left) 0 5/5 strength, no drift.
6. Motor Leg (Right) 0 5/5 strength, no drift.
7. Limb Ataxia 0 No ataxia present.
8. Sensory 0 Sensory intact.
Fluent speech with occasional paraphasic errors. Mild-
9. Best Language 1 to-moderate aphasia.
10. Dysarthria 0 Speech is fluent, no dysarthria noted.
11.
Extinction/Inattention 0 No extinction or inattention.
TOTAL NIHSS SCORE: 3
Clinical Interpretation: Mild stroke with isolated cognitive-linguistic deficits. This pattern
suggests a left hemisphere cortical lesion, likely involving posterior language areas (posterior
temporal/parietal region) without motor involvement.
PATIENT 2
Patient Scenario: A 72-year-old left-handed female presents 45 minutes after symptom onset.
She is drowsy but opens her eyes when called loudly. She answers her age correctly but not the
current month. She performs one command correctly (opens eyes) but cannot make a fist with
the other hand. She has rightward gaze preference that corrects with oculocephalic maneuver.
