COMPREHENSIVE CASE STUDY: NIH STROKE SCALE
(NIHSS) SCENARIO WITH QUESTIONS AND DETAILED
EXPLANATIONS - 2026/2027
Patient Scenario 1
Mr. John Doe is a 68-year-old right-handed male brought to
the emergency department by ambulance. His wife reports
that symptoms began suddenly 2.5 hours ago while he was
eating breakfast: he dropped his fork from his right hand, his
speech became slurred and nonsensical, and he could not
move his right arm or leg. He has a history of hypertension,
type 2 diabetes, atrial fibrillation (off anticoagulation) and a
prior transient ischemic attack. On arrival: blood pressure
185/95 mmHg, heart rate irregular, blood glucose 145 mg/dL,
no fever. Non-contrast CT head is pending.
You perform the NIHSS examination in the following
sequence, noting the patient’s exact performance:
The patient lies supine. He opens his eyes when you call his
name but appears drowsy and does not look around the room
spontaneously or maintain attention without stimulation. A
light tap on the shoulder arouses him to obey and respond,
though he drifts off quickly.
,LOC Questions: You ask, “What month is it?” He replies clearly,
“April.” You ask, “How old are you?” He stares blankly,
mumbles an unintelligible sound due to speech difficulty and
provides no correct number.
LOC Commands: You say, “Open and close your eyes.” He
performs this correctly on the first attempt. You say, “Grip and
release your left hand” (non-paretic side). He makes a clear
attempt but cannot complete the full grip-and-release motion
due to mild confusion/apraxia; the movement is incomplete
despite encouragement via pantomime.
Best Gaze: Testing horizontal eye movements, you move your
finger side to side. The patient’s eyes show partial restriction
when looking to the right (contralesional side); he has some
voluntary movement but not full range. No forced deviation.
Visual Fields: Confrontation testing (finger counting in all
quadrants). The patient reliably detects fingers in the left visual
fields but misses them partially in the right upper and lower
quadrants (clear asymmetry, including some quadrantanopia).
He has vision in both eyes.
Facial Palsy: You ask him to “show your teeth” and “raise your
eyebrows.” There is total or near-total paralysis of the lower
right face (flattened nasolabial fold, inability to smile on right);
upper face shows minor asymmetry. Grimace to noxious
stimulus confirms asymmetry.
, Motor Arm:
Left (non-paretic) arm placed at 90° (sitting equivalent): holds
position fully for 10 seconds with no drift.
Right (paretic) arm placed at 90°: no effort against gravity; the
limb falls immediately to the bed with no movement.
Motor Leg:
Left (non-paretic) leg held at 30°: holds position fully for 5
seconds with no drift.
Right (paretic) leg held at 30°: some effort against gravity but
falls to the bed within 5 seconds and cannot maintain position.
Limb Ataxia: Finger-nose-finger and heel-shin tests (eyes open,
intact visual field). No ataxia on the left side. On the right side,
there is clear ataxia out of proportion to the weakness
(overshooting and tremor during attempts).
Sensory: Pinprick testing on face, arms, trunk, and legs. The
patient feels pinprick normally on the left side but reports it as
“less sharp” or dull on the entire right side (mild to moderate
loss); he is aware of being touched.
Best Language: You show a picture of a scene and ask him to
describe it, name objects (e.g., “What is this?” pointing to a
key), and read/repeat simple sentences. His speech is
fragmentary with great need for inference and guessing by the
(NIHSS) SCENARIO WITH QUESTIONS AND DETAILED
EXPLANATIONS - 2026/2027
Patient Scenario 1
Mr. John Doe is a 68-year-old right-handed male brought to
the emergency department by ambulance. His wife reports
that symptoms began suddenly 2.5 hours ago while he was
eating breakfast: he dropped his fork from his right hand, his
speech became slurred and nonsensical, and he could not
move his right arm or leg. He has a history of hypertension,
type 2 diabetes, atrial fibrillation (off anticoagulation) and a
prior transient ischemic attack. On arrival: blood pressure
185/95 mmHg, heart rate irregular, blood glucose 145 mg/dL,
no fever. Non-contrast CT head is pending.
You perform the NIHSS examination in the following
sequence, noting the patient’s exact performance:
The patient lies supine. He opens his eyes when you call his
name but appears drowsy and does not look around the room
spontaneously or maintain attention without stimulation. A
light tap on the shoulder arouses him to obey and respond,
though he drifts off quickly.
,LOC Questions: You ask, “What month is it?” He replies clearly,
“April.” You ask, “How old are you?” He stares blankly,
mumbles an unintelligible sound due to speech difficulty and
provides no correct number.
LOC Commands: You say, “Open and close your eyes.” He
performs this correctly on the first attempt. You say, “Grip and
release your left hand” (non-paretic side). He makes a clear
attempt but cannot complete the full grip-and-release motion
due to mild confusion/apraxia; the movement is incomplete
despite encouragement via pantomime.
Best Gaze: Testing horizontal eye movements, you move your
finger side to side. The patient’s eyes show partial restriction
when looking to the right (contralesional side); he has some
voluntary movement but not full range. No forced deviation.
Visual Fields: Confrontation testing (finger counting in all
quadrants). The patient reliably detects fingers in the left visual
fields but misses them partially in the right upper and lower
quadrants (clear asymmetry, including some quadrantanopia).
He has vision in both eyes.
Facial Palsy: You ask him to “show your teeth” and “raise your
eyebrows.” There is total or near-total paralysis of the lower
right face (flattened nasolabial fold, inability to smile on right);
upper face shows minor asymmetry. Grimace to noxious
stimulus confirms asymmetry.
, Motor Arm:
Left (non-paretic) arm placed at 90° (sitting equivalent): holds
position fully for 10 seconds with no drift.
Right (paretic) arm placed at 90°: no effort against gravity; the
limb falls immediately to the bed with no movement.
Motor Leg:
Left (non-paretic) leg held at 30°: holds position fully for 5
seconds with no drift.
Right (paretic) leg held at 30°: some effort against gravity but
falls to the bed within 5 seconds and cannot maintain position.
Limb Ataxia: Finger-nose-finger and heel-shin tests (eyes open,
intact visual field). No ataxia on the left side. On the right side,
there is clear ataxia out of proportion to the weakness
(overshooting and tremor during attempts).
Sensory: Pinprick testing on face, arms, trunk, and legs. The
patient feels pinprick normally on the left side but reports it as
“less sharp” or dull on the entire right side (mild to moderate
loss); he is aware of being touched.
Best Language: You show a picture of a scene and ask him to
describe it, name objects (e.g., “What is this?” pointing to a
key), and read/repeat simple sentences. His speech is
fragmentary with great need for inference and guessing by the
