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Lethargy

Speak to the patient in a loud voice. For example, call the patient's name or ask "How are you?"

A lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep.

Obtundation

Shake the patient gently as if awakening a sleeper.

An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased.

Stupor

Apply a painful stimulus. For example, pinch a tendon, rub the sternum, or roll a pencil across a nail bed. (No stronger stimuli needed!)

A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment.

Coma

Apply repeated painful stimuli.

A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.

Neurologic Evaluation

RESPIRATIONS. Observe the rate, rhythm, and pattern of respirations. Because neural structures that govern breathing in the cortex and brainstem overlap those that govern consciousness, abnormalities of respiration often occur in coma.

PUPILS. Observe the size and equality of the pupils and test their reaction to light. The presence or absence of the light reaction is one of the most important signs distinguishing structural from metabolic causes of coma. The light reaction often remains intact in metabolic coma.

OCULAR MOVEMENT. Observe the position of the eyes and eyelids at rest. Check for horizontal deviation of the eyes to one side (gaze preference). When the oculomotor pathways are intact, the eyes look straight ahead.

OCULOCEPHALIC REFLEX (DOLL'S EYE MOVEMENTS). This reflex helps to assess brainstem function in a comatose patient. Holding open the upper eyelids so that you can see the eyes, turn the head quickly, first to one side and then to the other. (Make sure the patient has no neck injury before performing this test.)

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