A comprehensive clinical examination is the basis for selecting further diagnostic steps.
In principle, an emergency physical examination must first be performed in conscious comatose individuals:
Glasgow Coma Scale (GCS) – scale for estimating impaired 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 for each category separately and then added together. The maximum score is 15, the minimum 3 points.
- If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
- With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.
Subsequently, takes place:
- General physical examination – including blood pressure, pulse, body weight, height; furthermore:
- Inspection (viewing) of skin and mucous membranes; smelling breath [acetone odor/ketone bodies].
- Auscultation (listening) of the heart.
- Auscultation of the lungs
- Palpation (palpation) of the abdomen (abdomen) (pressure pain?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?) [pseudoperitonitis diabetica – condition of most severe abdominal pain in derailed diabetes mellitus with very high blood glucose values]
- Neurological examination – including checking reflexes and cranial nerve function [due todifferential diagnoses:
- Apoplexy (stroke)
- Basilar artery thrombosis – occlusion of a basilar artery of the brainstem associated with severe neurologic damage.
- Chronic subdural hematoma (cSDH) – hemorrhage between layers of the meninges that can lead to various neurological symptoms.
- Coma vigile (akinetic mutism) – muteness with general inhibition of motor functions, which is mainly conditioned in psychiatric diseases or injuries/tumors of the brain.
- Epilepsy
- Increased intracranial pressure
- Brain abscess – encapsulated collection of pus in the brain.
- Brain mass hemorrhage
- Cerebral sinus thrombosis – occlusion of a venous cerebral blood duct.
- Brainstem hemorrhage
- Brainstem infarction
- Meningoencephalitis – combined inflammation of the brain (encephalitis) and meninges (meningitis).
- Subarachnoid hemorrhage (SAB) – bleeding between the spinal meninges and the surface of the brain; in 75-80% of cases, the cause is an aneurysm (bulging of an artery)]
Square brackets [ ] indicate possible pathological (pathological) physical findings.