1A - Level of consciousness (stimulate, rub, pinch) - ✔✔ 0 - Alert; keenly responsive
1 - not alert, Arouses to minor stimulation
2 - Requires
... [Show More] repeated stimulation to arouse
3 - reflex movements only or totally unresponsive; Postures or unresponsive( use painful/noxious stimulus)
1B - Ask month and age - ✔✔ 0 - Both questions right
1 - One question right
1 - Dysarthric, intubated, trauma, or language barrier
2 - Aphasic
1C - "Blink eyes" and "Squeeze hands"
(ask pt to close eye, then open, L-hand make fist) - ✔✔ 0 - Performs both tasks
1 - Performs one task
2 - Performs neither task
2 - Best Gaze (Test horizontal extraocular muscles)
(position of eyes @ rest, spontaneous moving L or R, follow your finger; tract finger side to side) - ✔✔ 0 - Normal; no visual loss
1 - Partial gaze palsy: can be overcome; partial hemianopia. Partial gaze palsy: corrects with oculocephalic maneuver
2 - complete hemianopia. Forced gaze palsy: can not be overcome occulocephalic maneuver
3- bilateral hemianopia (blind including cortical blindness)
3 - Test visual fields (one hand cover eye, tell pt to look at your eyes/nose and does pt see which hand is moving then do with other eye) - ✔✔ 0 - No visual loss
1 - Partial hemianopia
2 - Complete hemianopia
3 - Patient is bilaterally blind
3 - Bilateral hemianopia
4 - Test facial palsy (use grimace if obtunded)
(show me your teeth/gum, lift eyebrows, close eyes as hard as you can)(symmetry of grimace is basis of scoring) - ✔✔ 0 - Normal symmetry
1 - Minor paralysis (flat nasolabial fold, asymmetric smile)
2 - Partial paralysis (lower face)
3 - Unilateral complete paralysis (upper/lower face)
3 - Bilateral complete paralysis
5A - Test left arm motor drift (extend arm 90 if sitting or 45 if supine)(start counting visually w/fingers when release arm) (start with non paretic arm) - ✔✔ 0 - No drift for 10 seconds
1 - Drift, but doesn't hit bed
2 - Drift, hits bed
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Amputation/joint fusion
5B - Test right arm motor drift - ✔✔ 0 - No drift for 10 seconds
1 - Drift, but doesn't hit bed
2 - Drift, hits bed
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Amputation/joint fusion
6A - Test left leg motor drift
(suspend leg at 30 degrees) - ✔✔ 0 - No drift for 5 seconds
1 - Drift, but doesn't hit bed
2 - Driift, hits bed
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Amputation/joint fusion
6B - Test right leg motor drift - ✔✔ 0 - No drift for 5 seconds
1 - Drift, but doesn't hit bed
2 - Driift, hits bed
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Amputation/joint fusion [Show Less]