Patient Identification. - -
Pt. Date of Birth / /
Hospital ( - )
Date of Exam / /
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ( )
1a. Level of Consciousness: The investigator must choos...
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes
[ ] 7-10 days [ ] 3 months [ ] Other (
)
1a. Level of Consciousness: The investigator must choose a 0= Alert; keenly responsive.
response if a full evaluation is prevented by such obstacles 1= Not alert; but arousable by minor stimulation
as an endotracheal tube, language barrier, orotracheal to obey, answer, or respond.
trauma/bandages. A 2= Not alert; requires repeated stimulation to attend, or is
3 is scored only if the patient makes no movement (other obtunded and requires strong or painful
than reflexive posturing) in response to noxious stimulation.
stimulation to make movements (not
stereotyped).
3= Responds only with reflex motor or autonomic effects or
totally unresponsive, flaccid, and areflexic.
1b. LOC Questions: The patient is asked the month and 1= Answers both questions correctly.
his/her age. The answer must be correct - there is no partial
credit for being close. Aphasic and stuporous patients who do 2= Answers one question correctly.
not comprehend the questions will score 2. Patients
unable to speak because of endotracheal intubation, Answers neither question correctly.
orotracheal trauma, severe dysarthria from any cause, 3=
language barrier, or any other problem not secondary to
aphasia are given a 1. It is important that only the initial
answer be graded and that the examiner not "help" the
patient with verbal or non-verbal cues.
1c. LOC Commands: The patient is asked to open and close 1 = Performs both tasks correctly.
the eyes and then to grip and release the non-paretic hand.
Substitute another one step command if the hands cannot 2 = Performs one task correctly.
be used. Credit is given if an unequivocal attempt is made
but not completed due to weakness. If the patient does not 3 = Performs neither task correctly.
respond to command, the task should be demonstrated to
him or her (pantomime), and the result scored (i.e., follows
none, one or two commands). Patients with trauma,
amputation, or other physical impediments should be given
suitable one-step commands. Only the first attempt is
scored.
2. Best Gaze: Only horizontal eye movements will be tested. 1 = Normal.
Voluntary or reflexive (oculocephalic) eye movements will be
scored, but caloric testing is not done. If the patient has a 2 = Partial gaze palsy; gaze is abnormal in one or both
conjugate deviation of the eyes that can be overcome by eyes, but forced deviation or total gaze paresis is not
voluntary or reflexive activity, the score will be 1. If a patient
present.
has an isolated peripheral nerve paresis (CN III, IV or VI),
score a 1. Gaze is testable in all aphasic patients. Patients
with ocular trauma, bandages, pre-existing blindness, or 3 = Forced deviation, or total gaze paresis not overcome
other disorder of visual acuity or fields should be tested with by the oculocephalic maneuver.
reflexive movements, and a choice made by the
investigator. Establishing eye contact and then moving
Rev
10/1/2003
, about the patient from side to side will occasionally clarify
the presence of a partial gaze palsy.
Time: : [ ]am [ ]pm
Rev
10/1/2003
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