Scale and Score in Clinical Medicine

Scale & Score in Clinical Medicine

Dr Puneet Kumar Misra

INTRODUCTION
During case taking of patients, clinician assess the entire physical and mental activities of it with the help of ask the question and with detail examination of it  , and  then build up a picture of its body state due to effect of disease, on the basis examination or response   of patient on  different   physical and mental activities . clinician makes a   score or grade of  its activity and after conclusion of  group of activity with the help of  various scale are  used in the clinical  practice. The details of various scales with its score or grade of various physical and mental activities pertain into it.

Scale & Score

Abbey and Dolorplus  Pain scale  –  Verbal rating scale. Different verbal descriptions are used to rate pain – ’no pain’, ‘mild pain’, ‘moderate pain’ and ‘severe pain’.

Visual analogue scale. A question is used, such as Over the past 24 hours, how would you rate your pain, if 0 is no pain and 10 is the worst pain you could imagine?’

Behavioural rating scale. It can be particularly difficult to decide whether a patient with cognitive impairment is suffering pain. A variety of measures are available which use observed behaviors , such as agitation and withdrawn posture, to assess levels of pain. Commonly used scales include Abbey and Dolorplus. Changes in behavioural rating pain scores can indicate whether drug measures have been successful. Regular recording of formal pain assessment and patient-rated pain scores improves pain management and reduces the time taken to achieve pain control.

AVPU score – it is simplification of the Glasgow coma scale .it is based on the basis patient alert, voice, pain and unresponsive state.

Bath Ankylosing   Spondylitis Diseases Activity Index – this activity index is based on the  experience expressed  by the patient related on the following  

Question  and its Score

1. How would you describe the overall level of fatigue or tiredness you have experienced? 1–10
2. How would you describe the overall level of neck, back or hip pain you have had? 1–10
3. How would you describe the overall level of pain and swelling you have had in joints other than the neck, back or hip? 1–10
4. How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure? 1–10
5. How would you describe the overall level of discomfort you have had from the time you wake up? 1–10
6. How long does your morning stiffness last from the time you wake up? 0 hr to 2+ hrs

The patient is asked to complete each question. The score is calculated by taking the average of all 6 questions, where duration of morning stiffness in minutes is coded in 12-minute increments from none (1) to 120 (10). 

Body Mass Index – it is useful in the categorizing under and over nutrition state of patient  by the help of weight of patient in KG and square of height  in the meters .For optimal health, the BMI should be 18.5–24.9 kg/m2.

Eastern Cooperative Oncology Group(ECOG) Performance Status Scale –  the  outcome of the patient suffering from malignancies is depend upon overall fitness of  it with appropriate therapeutic decisions  , this scale cantina  its fully active life to unable to carry out any self care under given option .

• 0 Fully active, able to carry on all usual activities without restriction and without the aid of analgesics
• 1 Restricted in strenuous activity but ambulatory and able to carry out light work or pursue a sedentary occupation. This group also contains patients who are fully active, as in grade 0, but only with the aid of analgesics
• 2 Ambulatory and capable of all self-care but unable to work. Up and about more than 50% of waking hours
• 3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
• 4 Completely disabled, unable to carry out any self-care and confined totally to bed or chair
• The outcome for patients with a performance status of 3 or 4 is worse in almost all malignancies than for those with a status of 0–2, and this has a strong influence on the approach to treatment in the individual patient

Elderly mobility scale or Barthel index of activities of daily living-   this scale is the assessment  of some daily activity and its nature i.e.

• Mobility -Independent = 3 Needs help = 2 Wheelchair independent = 1 Immobile = 0
• Stairs -Independent = 2 Needs help = 1 Unable = 0
• Transfers (e.g. from bed to chair) Independent = 3 Needs minor help = 2 Needs major help = 1 Unable = 0
• Bladder Continent = 2 Occasional incontinence = 1 Incontinent = 0
• Bowels Continent = 2 Occasional incontinence = 1 Incontinent = 0
• Grooming Independent = 1 Needs help = 0
• Toilet use Independent = 2 Needs help = 1 Unable = 0
• Feeding Independent = 2 Needs help = 1 Unable = 0
• Dressing Independent = 2 Needs some help = 1 Completely dependent = 0
• Bathing Independent = 1 Needs help = 0

The total score reflects the degree of dependency; scores of 14 and above are usually consistent with living in the community; scores below 10 suggest the patient is heavily dependent on carers.

Glasgow coma scale (GCS) – The GCS is used in the measured the conscious level .it is widely used in the medical coma on the basis of the eye-opening, verbal response and motor response score. The descriptions of scale are.

 Eye-opening (E) — • Spontaneous 4, • to speech 3, • to pain 2, • Nil 1.

Best motor response (M)– • Obeys commands 6,• Localises 5,• Withdraws 4,• Abnormal flexion 3,• Extensor response 2,• Nil 1.

Verbal response (V)–• Orientated 5, • Confused conversation 4, • Inappropriate words 3

• Incomprehensible sounds 2, • Nil 1

Coma score = E + M + V Always present GCS as breakdown, not a sum score (unless 3 or 15) • Minimum sum 3,• Maximum sum 15 

A description of eye opening (E2) and withdrawing (M4) to pain and making sounds only (V2) provides a much more useful picture than GCS 8

Modified Beighton Score for Joint Hyper Mobility –     this score is based on the clinical examination of given Clinical test  and its Score

• Extend little finger > 90° (1 point each side)
• Bring thumb back parallel to/touching forearm (1 point each side)
• Extend elbow > 10° (1 point each side)
• Extend knee > 10° (1 point each side)
• Touch floor with flat of hands, legs straight (1 point)
• Hypermobile = a score of 6 or more points out of a possible 9 for epidemiological studies, or 4 or more points (with arthralgia in four or more joints) for a clinical diagnosis of the benign joint hypermobility syndrome.

.Modified medical research council (MRC) dyspnoea scale – this scale grade the breathlessness with relation of activity .This scale useful  in the COPD patient .

 Grade Degree of breathlessness related to activities

• 0 No breathlessness, except with strenuous exercise
• 1 Breathlessness when hurrying on the level or walking up a slight hill
• 2 Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace
• 3 Stops for breath after walking about 100 m or after a few minutes on level ground
• 4 Too breathless to leave the house, or breathless when dressing or undressing
• (MRC = Medical Research Council)

Richmond agitation sedation scale (RASS)- this is clinical scale based on the response to voice and physical stimulation, it is used  when the patient in the ICU and require sedation and analgesia for ensure comfort.

The scale are Scoring in the given manner  of  Description

+4 – Combative – Overtly combative, or violent or immediate danger to staff

+3- Very agitated- Pulls on/removes tubes or catheters, or aggressive to staff

+2- Agitated – Frequent non-purposeful movement or patient–ventilator dyssynchrony

+1 –Restless– Anxious or apprehensive but no aggressive or vigorous movements

0  – Alert and calm

−1 -Drowsy -Not fully alert but sustained awakening (>10 secs) with eye opening/contact to voice

−2 –Light- sedation Brief awakening (< 10 secs) with eye contact to voice

−3 -Moderate -sedation Movement but no eye contact to voice

−4 -Deep sedation– Movement to physical stimulation but no response to voice

−5 -Unrousable -No response to voice or physical stimulation

Visual Infusion Phlebitis score(VIP) – The VIP score is a useful way of monitoring cannulae –related infection in the given manner .

 Clinical features Score Assessment and management

0 No signs of phlebitis – IV site appears healthy Observe cannula

1 Possible first signs of phlebitis Observe cannula One of the following is evident Slight pain near IV site Slight redness near IV site :

 2 Early stage of phlebitis Resite cannula  Two of the following are evident: Pain near IV site Erythema Swelling

3 Medium stage of phlebitis Resite cannula Consider treatment ALL of the following are evident and extensive: Pain along path of cannula ,Erythema ,Induration

4 Advanced stage of phlebitis or start of thrombophlebitis Resite cannula Consider treatment ALL of the following are evident and extensive: Pain along path of cannula,Erythema,Induration,Palpable venous cord

5 Advanced stage of thrombophlebitis Initiate treatment Resite cannula ALL of the following are evident: Pain along path of cannula,Erythema,Induration,Palpable venous cord,Pyrexia

Wells Score   – it is pre-test probability for the prediction of deep vein thrombosis on the basis of following feature of  Clinical characteristic  and its score Score

• Active cancer (patient receiving treatment for cancer within previous 6 mths or currently receiving palliative treatment) 1
• Paralysis, paresis or recent plaster immobilisation of lower extremities 1
• Recently bedridden for ≥ 3 days, or major surgery within previous 4 wks 1
• Localised tenderness along distribution of deep venous system 1
• Entire leg swollen 1
• Calf swelling at least 3 cm larger than that on asymptomatic side (measured 10 cm below tibial tuberosity) 1
• Pitting oedema confined to symptomatic leg 1
• Collateral superficial veins (non-varicose) 1
• Alternative diagnosis at least as likely as DVT −2

Clinical probability Total score 

DVT low probability ≤ 1 ,DVT moderate probability 1–2 ,DVT high probability ≥ 2

CONCLUSION

The above mentioned scale and score are much important for start of treatment and management of patient and its follow-up with the information and  nature of disorder.

• The all above scale are the totally based on the physical examination and observation of the clinician on the patient or explain by the patient or it’s attend.
• The scale and its score contents are gives the detail effect of the diseases on the different part of body and also help in search of corresponding  symptoms related to the diseases /disorder .
• The point of score in the different scale is the general symptoms of body in the different disorder/ diseases. But it’s in accurate manner and exact assessments   provide the better consequence of diseases.
• The point in the scale is same as the rubric found in the various repertory.
• The point in the scale are symptoms resemble with  the symptoms  in  the   various  materia  medica .
• The organon of medicine are advocacy in the aphorism “83 to 99 “ for investigating and tracing the picture of the disease as same manner mention in the different scale .
• Aphorism  [No 89] “When the patient (for  it is on him we have  chiefly to rely  for  a description of his  sensations, except  in the case of  feigned  diseases) has  by these details, given of his own  accord and  in  answer  to  inquiries, furnished the  requisite  information  and traced a tolerably perfect picture of the disease, the  physician is  at liberty and obliged (if he feels he has not   yet   gained  all the  information he needs) to ask more precise, more  special questions. “
• For the better analysis of the patients with its  management & treatment it is the need of current situation the use of repertory follow or based on the various scale & its score system.
• The various scale & score are also used in the clinical surgery, Pediatrics, and other specialist branch for determination of the patient condition.

 Reference 

1. Davidson Principal & practice of medicine 22^nd Edition
2. Harrison’s Principles of  internal medicine  18^th Edition
3. Pocket manual ofHomoeopathicMeteriaMedica with repertory.  W.Boericke
4. A Dictionary of Practical Materia Medica  By Clarke
5. Organon of Medicine by Samuel Hahnemann combined 5^th & 6^th editions      translated by Dr R E dudgeon & Dr W Boericke
6. Clark J.H. – Clinical Repertory.
7. Kent – Repertory (Expended)
8. Synthesis repertory

Dr Puneet Kumar Misra B.Sc, BHMS
Lecture (Practice of Medicine)
Govt Pt J LN H M C  Kanpur