1. Level of Consciousness (LOC)
1a: LOC - Response
Even if a complete assessment cannot be made (e.g., intubation, speech impairment, tracheal injury, and bandaging), the examiner must select one response. Score 3 points only if the patient does not respond to noxious stimuli (not reflexive).
LOC - Response
Please select
Alert, responsive
Drowsy, can be awakened with mild stimulation, can answer questions, follow commands
Stuporous or sluggish: requires repeated stimulation, strong or painful stimuli to elicit non-stereotypical responses
Comatose: only reflexive activities or spontaneous responses, or completely unresponsive, flaccid, no reflexes
1b: LOC - Questions
Ask for the current month and age. Score only the initial response. If the patient cannot understand the questions due to aphasia or coma, score 2 points; if unable to complete due to intubation, tracheal injury, severe dysarthria, language impairment, or any other reason (not caused by aphasia), score 1 point. Written answers are acceptable.
LOC - Questions
Please select
Both correct
One correct or unable to complete due to non-aphasic reasons like tracheal injury
Both incorrect or unable to understand the questions due to aphasia or coma (default coma scoring DCS)
1c: LOC - Commands
Open and close eyes; squeeze and release the fist on the non-paralyzed side. Each command may only be repeated once, and score only the initial response. If there is a clear effort but not completed due to weakness, consider it successful. If the patient cannot understand verbal commands, actions may be demonstrated without affecting the score. Appropriate commands should be given for those with injuries, amputations, or other physical defects.
LOC - Commands
Please select
Both correct
One correct
Both incorrect
2. Gaze
Only test horizontal eye movements. Score for voluntary or reflexive eye movements. If gaze deviation can be corrected by voluntary or reflexive activity, score 1 point. If there is isolated peripheral oculomotor palsy, score 1 point. Gaze can be tested in individuals with aphasia. For eye trauma, bandaging, blindness, or other visual or field defects, the examiner should select a reflexive movement to test. Establish eye contact with the patient and then move from one side to the other to determine gaze paralysis by the patient's ability to maintain eye contact.
Horizontal Eye Movement
Please select
Normal
Partial gaze paralysis (abnormal gaze in one or both eyes, but no forced gaze or complete gaze paralysis); isolated peripheral oculomotor palsy
Forced gaze or complete gaze paralysis (cannot be overcome by head-eye reflex)
3. Visual Fields
Keep both eyes focused straight ahead, cover one eye, if the patient can see several fingers in the upper or lower quadrant of the other side, it is considered normal. If there is unilateral blindness or eye removal, check the other eye. Score 1 point for clear asymmetric blindness (including quadrant blindness). Score 3 points for complete blindness (any cause). Score 1 point for being near death. Responses can be made through actions.
Visual Fields
Please select
No visual field defects
Clear asymmetric blindness (including partial blindness) or near death
Complete blindness
Bilateral blindness (including cortical blindness) or complete blindness for any reason
4. Facial Palsy
Is the facial expression symmetrical? The patient is required to smile, close their eyes tightly, raise their eyebrows, etc. If the patient cannot understand the instructions, actions may be demonstrated, or noxious stimuli may be used to observe the patient's expression.
Facial Palsy
Please select
Normal
Mild (nasolabial fold flattened and asymmetrical when smiling)
Partial (complete or nearly complete paralysis of the lower face)
Complete (unilateral or bilateral paralysis, lack of movement in upper and lower face)
5. Upper Limb Movement
Position the limb appropriately: sitting, raised at 90º; lying down, raised at 45º, palms facing down. The patient is required to maintain this position for 10 seconds. For aphasic patients, encourage them with words or gestures, avoiding harmful stimuli. The evaluator may raise the patient’s upper limb to the required position, encouraging the patient to hold it. Check each limb in sequence, starting from the upper limb on the non-affected side. Amputees or patients with joint fusion should skip this test, but it should be recorded.
Upper Limb Movement
Please select
In the required position, no drop within 10 seconds
Dropped within 10 seconds; unable to maintain the required position but did not touch the bed or other support
Attempted to resist gravity but dropped to the bed or other support within 10 seconds
Unable to resist gravity; limb immediately dropped but can perform some movements (e.g., shrugging)
No movement; unable to initiate voluntary movement of the upper limb
Default coma score (DCS)
6. Lower Limb Movement
Raise the lower limb in a lying position to 30º and hold for 5 seconds; encourage the patient with words or gestures, avoiding harmful stimuli. The evaluator may raise the patient’s lower limb to the required position, encouraging the patient to hold it. Check each limb in sequence, starting from the lower limb on the non-affected side. Amputees or patients with joint fusion should skip this test, but it should be recorded.
Lower Limb Movement
Please select
In the required position, no drop within 5 seconds
Dropped within 5 seconds; unable to maintain the required position but did not touch the bed or other support
Attempted to resist gravity but dropped to the bed or other support within 5 seconds
Unable to resist gravity; limb immediately dropped but can perform some movements (e.g., hip flexion)
No movement; unable to initiate voluntary movement of the lower limb
Default coma score (DCS)
7. Limb Ataxia
Limb Ataxia
Please select
No ataxia: movements are smooth and accurate
One limb has ataxia: movements are stiff or inaccurate
Two or more limbs have ataxia: movements are stiff or inaccurate on one side
8. Sensation
Check the patient’s distal limbs for pinprick sensation and observe their facial expression, or assess how patients with consciousness disturbances or aphasia react to harmful stimuli. Scoring only applies to sensory loss due to stroke. Patients with hemibody sensory loss require precise testing across multiple body parts: upper limbs (excluding hands), lower limbs, torso, and face. Bilateral sensory loss due to brainstem stroke scores 2 points.
No sensory loss
Mild to moderate sensory loss: the patient perceives pinprick as dull or blunt, or pinprick is absent but there is touch sensation
One side has severe to complete sensory loss: completely no touch sensation on one side of the body. Default coma score (DCS)
9. Language
Naming and reading tests: Describe a scene based on a picture, read several sentences, name several objects in the picture. Record the patient’s best score. If visual impairment interferes with the test, allow the patient to identify objects placed in their hand and repeat or pronounce. Patients on a ventilator can write their answers. For confused or uncooperative patients, choose a score, but give 3 points only to those who cannot speak and cannot follow any commands.
Normal: no language function barriers
Mild to moderate aphasia: fluency and comprehension partially decreased, but expression is not significantly limited
Severe aphasia: speech is fragmented, requiring listeners to infer, question, or guess; communication is difficult
Complete aphasia: unable to speak or understand spoken language. Default coma score (DCS)
10. Dysarthria
Read or repeat the words on the list. If there is severe aphasia, assess the clarity of pronunciation during spontaneous speech. Patients who are intubated or unable to pronounce due to other physical barriers skip this test but should be recorded.
Normal: clear and fluent pronunciation
Mild to moderate dysarthria: some unclear pronunciations but can be understood
Severe dysarthria: speech is unclear, cannot be understood, or loss of voice. Default coma score (DCS)
11. Neglect
Assessing the patient's ability to recognize simultaneous skin sensation and visual stimuli on both sides to determine if the patient has neglect. If the patient has severe visual impairment affecting bilateral visual tests, but skin sensation is normal, the score is recorded as 0. If the patient is aphasic but shows attention to both sides, the score is also recorded as 0.
Normal: Correctly answers all questions
Visual, tactile, auditory, or spatial neglect: Neglect of one side under a certain stimulus condition.
Hemispatial neglect: Neglect of the same side under more than one stimulus condition. Default Coma Score (DCS).
Home
Back