A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- Assessment of consciousness using the Glasgow Coma Scale (GCS).
- General physical examination – including blood pressure, pulse, body weight, height; furthermore:
- Inspection (viewing).
- Skin and the mucous membranes
- Neck vein congestion?
- Central cyanosis? (bluish discoloration of skin and central mucous membranes, e.g., tongue).
- 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 [tachycardia (too fast heartbeat: > 100 beats per minute); due topossible sequelae: heart failure (cardiac insufficiency)].
- Auscultation of the lungs [respiratory arrest?]
- Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, renal bearing knocking pain?)
- Inspection (viewing).
Square brackets [ ] indicate possible pathological (pathological) physical findings.Glasgow Coma Scale (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 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.