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LOC

0= alert
1= not alert, aroused with verbal stimulation
2= not alert, aroused by strong painful stimulation
3= reflex movements only or totally unresponsive

1B LOC Questions: month of the year, year of age
0= answers both correctly
1= one answer correct, language barrier, ET tube
2= no questions correct, coma, unconscious

1C close your eyes, open eyes, left hand fist, open hand
0= both task perform correctly
1= perform one task
2= perform no task, cognitive impairment

Best Gaze- voluntary horizontal eye movement, follow finger side to side
0= Normal
1= partial gaze palsy- coma pts
2= forced deviation

Visual- peripheral vision, cover one eye
0= no visual loss
1= partial hemianopia
2= complete hemianopia
3= bilateral hemianopia (blind)

Facial Palsy-commands show me ur teeth, close eyes tight, open eyes, raise
eyebrows
0=Normal
1= minor paralysis
2= partial paralysis- lower face, clear cut asymmetry of smile
3= Complete paralysis of upper and lower face

Motor Arm- hold up arm at 90 degree sitting or 45 supine for 10 seconds, not scored
if amputated
0= no drift
1= drift or jerks but can maintain up for 10 sec
2= some effort against gravity
3= no effort against gravity, can make voluntary movements
4= no movement, unable to make voluntary movements, LOC 3

Motor Leg- always assess supine elevated in 30 degrees, count for 5 seconds
0= normal, no drift
1= drift, falls but doesnt hit surface
2= some effort against gravity but falls to surface
3= no effort against gravity but can move the leg
4= no movement

Limb Ataxia- finger to nose, heel to shin
0=absent, normal coordination, paralyzed or cant understand
1= present in one limb, ataxia present and out of proportion to weakness
2= present in two limbs

Sensory- pinpricks, test opposite sides
0= normal, no sensory loss
1= mild to moderate sensory loss
2= severe or total loss of sensory, LOC 3

Language- describe picture, picture identification, read sentences
0= no aphasia
1= mild to moderate aphasia, loss of fluency and comprehension, understandable
2= severe aphasia, incomprehensible, cant decipher what the pt is saying
3= mute, global aphasia

Dysarthria- articulation and clarity of speech, give list of words
0= normal speech, no slurring
1= mild-to moderate slurring, still understandable
2= severe slurring, cant be understood, mute, unresponsive, LOC 3

Extinction and Inattention- close eyes, touch opposite sides; vision
0= no abnormality
1= visual, tactile, auditory, spatial or personal inattention
2= profound hemi inattention or extinction to more than one modality; LOC 3






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