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Test your knowledge on some disorders of consciousness and what the Glasgow Coma Score is!

Reviewed by Jonathan Loomes-Vrdoljak, 23 February 2020

Consciousness

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Question 1
What are the maximum and minimum scores an individual can achieve on the Glasgow Coma Scale?
A
Maximum 10 Minimum 0
B
Maximum 15 Minimum 0
C
Maximum 15 Minimum 3
D
Maximum 12 Minimum 4
E
Maximum 15 Minimum 1
Question 1 Explanation: 
The Glasgow Coma Score is used to assess the level of consciousness of an individual. The maximum score an individual can get is 15/15. The minimum score is 3/15. A deceased individual will gain a 3/15. Just remember, no one can score less than 3!
Question 2
What three areas does a Glasgow Coma Score (GCS) assess? (Select 3 answers)
A
Best fine motor response
B
Best cognitive response
C
Best verbal response
D
Best eye response
E
Best motor response
Question 2 Explanation: 
GCS assess best motor response, best verbal response and best eye opening response.
Question 3
A member of staff tells you they are worried about a patient. The patient is mumbling phrases "need my passport" and "the plane will take off without me"  in response to being asked if they are okay, thrashing their arms around and glancing around the room. They move their arms and legs when asked. What is their GCS score?
A
E- 4 V- 2 M- 6 GCS 12/25
B
E- 4 V- 3 M- 5 GCS 12/15
C
E- 4 V- 3 M- 6 GCS 13/15
D
E- 3 V- 4 M - 4 GCS 11/15
E
E- 1 V-1 M-1 GCS 3/15
Question 3 Explanation: 
Eyes - They are opening spontaneously scores 4/4 points Voice - The patient is using inappropriate words so scores 3/5 Motor- The patient is moving all four limbs on command so scores 6/6 4 + 3 + 6 = 13/15
Question 4
A 23 year old is brought into Accident and Emergency following a bike crash. The patient is sat up talking to you, making eye contact, explaining "Oh I clipped the curb, that's what caused me to fall off". They are moving all limbs on command. What this this individual's GCS?
A
E- 5 V- 4 M- 6 GCS 15/15
B
E- 6 V-4 M- 5 GCS 15/15
C
E-3 V-5 M- 7 GCS 15/15
D
E- 4 V-5 M- 6 GCS 15/15
E
E-4 V-7 M-4 GCS-15/15
Question 4 Explanation: 
This individual is clearly alert and fully orientated so is GCS 15/15. This was designed to test whether you know the individual categories maximum scores. Eyes scores a maximum of 4 Voice scores a maximum of 5 Motor scores a maximum of 6
Question 5
A patient rapidly deteriorates, you assess their GCS to be 8/15.  (E- 1, V-2, M-5). With this score, what do you need to immediately consider?
A
The patient's kidney and urinary bladder ultrasound results from 2 weeks ago.
B
That the patient needs airway and ventilation interventions
C
The patient's blood glucose as you know they have type 1 diabetes mellitus
D
Order a urgent CT head to rule out an intracranial haemorrhage
E
Ask for another set of observations to be done
Question 5 Explanation: 
"Less than 8, ventilate!" A patient with a GCS less than 8 is in danger of having airway and respiratory compromise so you must remember your ABCDE approach. An airway problem will kill this patient faster than hypoglycaemia or an intracranial haemorrhage. Another set of observations is again important but the airway issue takes precedence. Hopefully you understand why ultrasound results from 2 weeks ago is not immediately relevant in this situation.
Question 6
Persistent vegetative state is an abnormality of consciousness. What is the pathophysiology of persistent vegetative state?
A
Sensation, reticular formation and cortical functions are all intact, but motor function is absent
B
Reticular formation intact but connection with the cerebral cortex is non-functional
C
The reticular formation is not intact but connection with the cerebral cortex is functional
D
Both cortical and reticular formations are non-functional
E
There is brainstem death.
Question 6 Explanation: 
Persistent vegetative state is when a person is awake (eyes are open and sleep-wake cycles are present), but awareness and meaningful responses are absent. The reticular formation has a major role in the sleep/wake cycle and remains intact but the connection with the cerebral cortex is non-functional in persistent vegetative state.
Question 7
What is "Locked-in" Syndrome?
A
Patient is fully awake and aware, but motor function is completely absent
B
Patient is fully awake and aware, motor function absent bar vertical eye movements
C
Patient is partially awake and aware, gross motor function is preserved
D
Patient is partially awake and aware, motor function is absent bar vertical eye movements
E
Patient isn't conscious but eye movements are preserved
Question 7 Explanation: 
"Locked-in" syndrome is usually due to an infarct in ventral pons involving the corticobulbar and corticospinal tracts. Sensation, reticular formation and cortical function remains intact so the person is fully awake and aware. However, motor function is mostly absent, only vertical eye movements and eyelid elevation may be spared, hence the description "Locked in" as the individual is aware of everything but can only move their eyes vertically.
Question 8
Calculate the GCS from the following information: Patient is sat up in bed making eye contact with you, shortly after 09:00. They are able to hold a conversation but keep repeating "Is it nearly tea time?". When asked to move their limbs, they are unable to due to a previous spinal cord injury which means they are paralysed.
A
E- 4 V- 4 M- 1 GCS 9/15
B
E- 4 V- 3 M-6 GCS 13/15
C
E-4 V-4 M- Not testable GCS 8
D
E- 3 V-4 M- Not testable GCS 7
E
Insufficient information to calculate their GCS
Question 8 Explanation: 
Eyes are spontaneously open so scores 4 points Verbal - there is some confusion as they keep repeating "Is it nearly tea time?" when in the stem it tells you it is shortly after 09:00. Therefore they score 4 Motor- This is not testable. With motor you score the patient based on the highest scoring response in any single limb. They cannot move any limb thus, motor is not testable in this individual. This would need to be explained as someone would wrongly assume a GCS of 8 out of 15 indicating a serious head injury.
Question 9
A patient collapses in the waiting room, you go and assess them. They open their eyes when a trapezius squeeze is performed, but only make groaning noises. In addition when the trapezius squeeze is performed, their head, arms and legs extend. The palms of their hands are turned away from their body. Their GCS is E-2, V-2, M- 2 Where could the lesion be in this individual? (select 2)
A
Pons
B
Frontal lobe
C
Midbrain
D
Cerebellum
E
Thalamus
Question 9 Explanation: 
This is a challenging question so please don't panic if this didn't make sense. Firstly let's think about what the GCS and stem are telling us. I hope you will agree this individual is quite unwell. They are only responsive to pain stimuli (trapezius squeeze) in all three areas. The motor symptoms are key here. This is an abnormal extension response to pain, also known as decerebrate posturing. Having a look at a cartoon of decerebrate posturing may help to make the description in the stem more clear. So now let's think what does decerebrate posturing mean? This indicates brain stem damage. These signs will be exhibited in people with lesions or compression in the midbrain or lesions in the cerebellum. You might be wondering why the pons isn't involved. A separate descending pathway called the pontine reticulospinal tract originates in the pons. It receives pain signals from the spinothalamic tract and initiates an extension response Thus the correct answers are midbrain and cerebellum.
Question 10
Abnormal flexion response to pain (decorticate posturing) when assessing a motor response, indicates there may be damage to what areas of the brain? Select 3
A
Substantia nigra
B
Cerebral hemispheres
C
External capsule
D
Internal capsule
E
Thalamus
Question 10 Explanation: 
Abnormal flexion response involves the adduction of the arm, internal rotation of the shoulder, pronation of the forearm and wrist flexion. This is known as decorticate posturing. (It may be helpful to look at a cartoon of decorticate posturing.) This indicates that there may be significant damage to the cerebral hemispheres, internal capsule and thalamus. In decorticate posturing the red nucleus is preserved. The red nucleus triggers flexion which overrides the extention signals from the pons so the arms flex upwards
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