A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- Assessment of consciousness using the Glasgow Coma Scale (GCS) (see below).
- General physical examination – including blood pressure, pulse, body weight, height; furthermore:
- Inspection (viewing).
- Skin and mucous membranes
- Abdomen (abdomen)
- Shape of the abdomen?
- Skin color? Skin texture?
- Efflorescences (skin changes)?
- Pulsations? Bowel movements?
- Visible vessels?
- Scars? Hernias (fractures)?
- Auscultation (listening) of the heart.
- Auscultation of the lungs
- Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?)
- Inspection (viewing).
- Neurological examination [due topossible symptoms:
- Amnesia, retrograde and antegrade – amnesia preceding and following the triggering event in time (memory impairment).
- Cephalgia (headache)
- Vertigo (dizziness)]
[due todifferential diagnoses:
- Compressio cerebri (cerebral contusion).
- Contusio cerebri (cerebral contusion)]
Square brackets [ ] indicate possible pathological (pathological) physical findings.
Glasgow Coma Score (GCS) – scale for estimating a disorder of consciousness:
Criterion | Score | |
Eye opening | spontaneous | 4 |
on request | 3 | |
on pain stimulus | 2 | |
no reaction | 1 | |
Verbal communication | conversational, oriented | 5 |
conversational, disoriented (confused) | 4 | |
incoherent words | 3 | |
unintelligible sounds | 2 | |
no verbal reaction | 1 | |
Motor response | Follows prompts | 6 |
Targeted pain defense | 5 | |
untargeted pain defense | 4 | |
on pain stimulus flexion synergisms | 3 | |
on pain stimulus stretching synergisms | 2 | |
No response to pain stimulus | 1 |
Assessment
- Points are awarded separately for each category and then added together. The maximum score is 15 (fully conscious), the minimum 3 points (deep coma).
- If the score is 8 or less, very severe brain dysfunction must be assumed and there is a risk of life-threatening respiratory failure.
- With a GCS less than or equal to 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose to secure the airway) must be considered.