Neurological Assessment

Transcription

1 Neurological Assessment Name: Age: Gender: Date: History Review of history related to neurological system YES/NO If YES, provide details: General Neurological Mental Illness Neurological disease Severe or persistent headaches Head injury Convulsions Tremor/weakness Recent injury Speech difficulty Numbness/tingling Neurological pain Dysphagia Gait problems Coordination problems Dizziness Spinal cord injury - Memory difficulties Learning disorder Substance abuse Sleep pattern/difficulties: Allergies (and responses): Neurological System Page 1 of 5

2 Current medications: Family history neurological system: Review of history related to the current visit: Focused symptom analysis of current problem: Reason for visit: Character: Onset: Duration: Location: Severity: Associated problems: Efforts to treat: Physical Assessment Mental Status LOC (level of consciousness): Orientation (person, time, place): Dress and grooming: Behavior (appropriateness): Speech (intelligible, pace): Mood/affect (facial expression, attitude): Memory (recent, remote): Cognitive (reading, writing, abstract reasoning, judgment): Thought processes (content, logic): Suicidal thoughts (spontaneous expression, response to examiner): See also Mini Mental Status Exam. Inspection General characteristics (posture, body position, noted weaknesses): Neurological System Page 2 of 5

3 Cranial Nerves CRANIAL NERVE ASSESSMENT FINDINGS I Olfactory Smell Odor recognition II III IV V Optic Oculomotor Trochlear Trigeminal Visual acuity Visual fields Raise eyelids Extraocular eye movements Eye movement inward and downward Chewing Clenching teeth Sensations on forehead VI Abducens Lateral eye movements VII VIII IX X XI Facial Acoustic Glossopharyngeal Vagus Spinal Accessory Facial expressions Taste anterior twothirds of tongue Secretion tears and saliva Hearing Equilibrium Swallowing Gag reflex Taste posterior third of tongue Salivary gland secretion Speech phonation Swallowing Sensation behind ear Gag reflex Turn head Shrug shoulders XII Hypoglossal Tongue movement Motor Function General characteristics (general response, client cooperation): Neurological System Page 3 of 5

4 MOTOR FUNCTION Gross Motor Balance Fine Motor Upper Extremities Place check in of technique used. Record appropriate findings. Findings: Tone, Strength TECHNIQUE USED Ambulation Gait Romberg Finger-to-finger touching Rapid alternating movements Heel-to-shin movement Fine Motor Lower Extremities Heel toe walking Sensory Function General characteristics (general response, client cooperation): Place check in of technique used. Record appropriate findings. SENSORY FUNCTION TECHNIQUE USED FINDINGS Superficial touch sensation Temperature sensation Sensation of position Touch Pressure sensation Vibratory sensation over bony prominence Alternating sharp dull Correct identification of object (stereognosis) Cortical Sensory Two-point discrimination Correct identification of marking (graphesthesia) Neurological System Page 4 of 5

5 Deep Tendon Reflexes General characteristics (body position, tendon response, client cooperation): TENDON REFLEX ASSESSMENT REPORTED GRADE Biceps Tendon Biceps contraction and the forearm flexion at the elbow Triceps Tendon Brachioradialis Tendon Patellar Tendon Achilles Tendon Plantar Tendon (Babinski) Contraction of the triceps muscles with extension of the elbow The forearm pronation with flexion at the elbow Contraction of the quadriceps muscle with knee extension Plantar flexion of the foot Flexion of toes inward and downward REFLEX GRADE ++++ Brisk, hyperactive, clonus of tendon +++ More brisk than expected ++ Normal + Slightly diminished response 0 No response Analysis: Neurological System Page 5 of 5