If physical obstacles such as tracheal intubation, language barrier, facial or tracheal injury/bandaging prevent a full evaluation, use discretion. Grade “3” should be chosen only in the case when the patient does not react with movements (except for reflex ones) to painful stimuli

Ask the patient how old he is and how old he is. The answer must be exact – do not give part of the points for an approximate answer. Patients with aphasia or significant impairment of consciousness who do not understand the question receive a score of “2”. Patients who are unable to speak due to tracheal intubation, facial or tracheal injury/bandage, severe dysarthria (for any reason), language barrier, or other problem not caused by aphasia receive a “1”. It is important to evaluate only the first response and not to help the patient with any words or actions

Ask the patient to open and close the eyes and make a fist and spread the fingers of the less affected hand. If the fingers cannot be used, give another command that involves one action. When the attempt was clear, but it was not completed due to muscle weakness, a point is awarded for it. If the patient does not understand the verbal command, show the task (using sign language) and evaluate the response (did not perform any, performed both or one of the commands). For a patient with physical injuries, amputation of an arm, or other disabilities, give another simple one-step order. Rate only the first attempt

Assess only horizontal eye movements. Score for voluntary or reflex (oculocephalic reflex) eye movements, without caloric tests. If the patient’s eyeballs are turned sideways in pairs, but during voluntary or reflex movements their position changes, the score is “1”. If the patient has a peripheral lesion of the cranial nerve that provides movements of the eyeball (III, IV or VI), the score is “1”. Assess eye movements in all patients with aphasia. In a patient with eye injuries, bandages, blindness and other violations of acuity or visual fields, reflex movements should be checked – the choice is left to the clinician. Sometimes movements in one direction and in the other direction away from the patient while maintaining contact between the eyes make it possible to detect partial paralysis of the gaze

Assess the upper and lower quadrants of the visual fields using a confrontational test (counting fingers or, if not possible, threatening eye movements). You can encourage the patient, but if the patient accordingly looks in the direction of the moving finger, evaluate it as normal. If one eye is blind or removed, assess the visual fields of the other eye. The grade “1” is given only in case of clear asymmetry of the visual fields, including quadrantanopsia. If the patient is blind (for any reason), score “3”. Immediately perform simultaneous double stimulation. If there is a selective lack of attention, give the patient 1 point and take this into account in section 11

Ask (or encourage with gestures) that the patient shows his teeth, raises his eyebrows and closes his eyes tightly. In patients with impaired consciousness or those who do not understand speech, assess the symmetry of grimaces and response to painful stimuli. If the face is not visible (due to injury/bandaging, tracheal intubation, or other reasons), remove all obstructions as much as possible

Assess each limb in turn, starting with the least affected. Give the patient’s hand the initial position: straighten the patient’s hand (palm down) at an angle of 90 degrees (if the patient is sitting) or 45 degrees (if the patient is lying) to the body – and ask him to hold it like that. Lowering means the downward movement of the hand in the first 10 seconds. Encourage the patient with aphasia with a commanding voice and gestures, but do not cause pain. For cases of amputation or ankylosis of the shoulder joint only, indicate that this section cannot be assessed (U/A – cannot be assessed) and provide a clear written explanation

Assess each limb in turn, starting with the least affected (always in a horizontal, face-up position on the back). Give the patient’s leg the starting position: at an angle of 30 degrees to the bed – and ask him to hold it like that. Lowering means the downward movement of the leg in the first 5 seconds. Encourage the patient with aphasia with a commanding voice and gestures, but do not cause pain. For cases of hip amputation or ankylosis only, indicate that this section cannot be assessed (U/A) and provide a clear written explanation

In this section, signs of unilateral damage to the cerebellum are revealed. Ask the patient to keep his eyes open during the examination. In case of visual disturbances, perform the test in the preserved field of vision. Perform “toe-nose-toe” and “heel-knee” tests on both sides; score for ataxia only when the ataxia is greater than the weakness. If the patient does not understand speech or is paralyzed, there is no ataxia (score 0). In cases of amputation or joint ankylosis only, indicate that this section cannot be assessed (U/A) and write a clear explanation

Assess the patient’s sensitivity or grimaces during injections with a disposable pin or avoidance of painful stimuli (in case of significant impairment of consciousness or aphasia). Consider only the loss of sensitivity from a stroke. Check carefully in different parts of the body (arms, but not hands, legs, torso, face) to reliably rule out hemihypesthesia. Score “2” only when there is no doubt that the patient has a very significant or complete loss of sensitivity. Therefore, rate a patient with impaired consciousness or aphasia as “1” or “0”. Give 2 points to a patient with a truncal stroke and bilateral loss of sensation. If the patient is unresponsive and has tetraplegia, determine the score “2”. Immediately give 2 points to a patient in a coma (score “3” in subsection 1A) in this section

Ask the patient to describe what is depicted in the proposed picture, name the depicted things and read the sentence. Assess language comprehension based on responses and following commands during a general neurological examination. If visual disturbances interfere with the examination, ask the patient to name things that are placed in his hand, repeat phrases and speak. In the case of tracheal intubation, ask the patient to write. A patient in a coma (score “3” in subsection 1A) immediately receives 3 points in this section. If patient 42 is unconscious or uncooperative, rate the patient at your own discretion, but assign 3 points only when the patient is mute and unresponsive

When there are no significant disturbances, assess the patient’s pronunciation by asking him to read and repeat the words on the page. If the patient has severe aphasia, assess the clarity of pronunciation and spontaneous speech. Only in the case of intubation or other physical barriers to speech, indicate that this section is not assessable (U/A) and provide a clear written explanation. Do not explain to the patient exactly what you are evaluating

During the preliminary examination, you may have received quite a bit of information about lack of attention or selective perception. If simultaneous double stimulation is not possible due to significant narrowing of the visual fields (hemianopsia), and skin sensitivity is preserved, choose a score of “0”. If a patient with aphasia pays attention to stimuli from both sides, the score is “0”. If there is a lack of visual attention to part of the space or anosognosia, this confirms the disorder. Since these violations are only assessed when they are present, this section is never unassessable

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