Tina Jones Neurological shadow health assessment Objective Data

Tina Jones Neurological shadow health assessment Objective Data
Tina Jones Neurological shadow health assessment Objective Data
Objective Data Collection: 36.75 of 37 (99.32%)
 Correct
 Partially correct
 Incorrect
 Missed
 Confirmed orientation
1 of 1 point
To Person (1/3 point)
 Oriented to person
 Not oriented to person
To Place (1/3 point)
 Oriented to place
 Not oriented to place
To Time (1/3 point)
 Oriented to time
 Not oriented to time
 Evaluated abstract thinking
1 of 1 point
Abstractness (1/2 point)
 Abstract
 Concrete
Relevance (1/2 point)
 Relevant
 Not relevant
 Evaluated attention span
1 of 1 point
Serial 7s Test (1/1 point)
 Accurate
 Not accurate
 Evaluated comprehension
1 of 1 point
Observations (1/1 point)
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CHAT US TO PLACE OUR ORDER AND SCORE 100%
 Able to follow instructions
 Unable to follow instructions
 Evaluated general knowledge
1 of 1 point
Accuracy (1/1 point)
 Accurate
 Not accurate
 Evaluated judgment
1 of 1 point
Observations (1/1 point)
 Intact
 Not intact
 Evaluated memory
1 of 1 point
Remote Memory (1/3 point)
 Intact
 Not intact
Immediate Memory (1/3 point)
 Intact
 Not intact
New Learning Ability (1/3 point)
 Accurate
 Not accurate
 Observed vocabulary
1 of 1 point
Complexity (1/1 point)
 Expected complex for patient’s age, education level, and general ability
 Not expected complexity
Tina Jones Neurological shadow health assessment Objective Data
 Observed articulation
1 of 1 point
Observations (1/1 point)
 No observed problems with pronunciation or expression
 Imprecise pronunciation of consonants
 Slurring
 Hesitation
 Stutter
 Tested olfactory nerve
1 of 1 point
Sense Of Smell (1/2 point)
 Able to discriminate
 Not able to discriminate
Symmetric (1/2 point)
 Symmetric bilaterally
 Asymmetric
 Tested visual acuity (optic nerve)
1 of 1 point
Right (1/2 point)
 20/100
 20/70
 20/50
 20/40
 20/30
 20/25
 20/20
 20/15
 20/13
 20/10
Left (1/2 point)
 20/100
 20/70
 20/50
 20/40
 20/30
 20/25
 20/20
 20/15
 20/13
 20/10
 Examined retina with ophthalmoscope (optic nerve)
0.75 of 1 point
Right: Fundus (No point)
 No visible abnormal findings
 Myelinated nerve fibers
 Papilledema
 Glaucomatous cupping
 Drusen bodies
 Cotton wool bodies
 Hemorrhage
Right: Disc Margin (1/4 point)
 Sharp
 Blurred
Left: Fundus (1/4 point)
 No visible abnormal findings
 Myelinated nerve fibers
 Papilledema
 Glaucomatous cupping
 Drusen bodies
 Cotton wool bodies
 Hemorrhage
Left: Disc Margin (1/4 point)
 Sharp
 Blurred
 Inspected pupils (optic and oculomotor nerves)
1 of 1 point
Observations With Penlight (1/1 point)
 No visible abnormal findings (PERRL)
 Unequal
 Irregular
 Miosis
 Mydriasis
 Non-reactive to light
 Tested extraocular eye movements (extraocular movements: oculomotor, trochlear, abducens nerves)
1 of 1 point
Cardinal Fields (1/2 point)
 No visible abnormal findings
 Nystagmus
 Fixed pupil
Convergence (1/2 point)
 No visible abnormal findings
 Unequal bilaterally
 Fixed pupil
 Tested facial sensation (trigeminal nerve)
1 of 1 point
Observations (1/1 point)
 Intact
 Unable to feel dull stimulus
 Unable to feel sharp stimulus
 Unable to feel soft stimulus
 Inspected head and face (facial nerve)
1 of 1 point
Skull Symmetry (1/2 point)
 Symmetric
 Asymmetric
Facial Feature Symmetry (1/2 point)
 Symmetric
 Asymmetric
 Performed Weber test (auditory nerve)
1 of 1 point
Results (1/1 point)
 Normal
 Conductive or sensorineural loss
 Performed Rinne test (auditory nerve)
1 of 1 point
Right (1/2 point)
 Normal
 Conductive loss
Left (1/2 point)
 Normal
 Conductive loss
 Tested gag reflex (glossopharyngeal, vagus nerves)
1 of 1 point
Observations (1/1 point)
 Intact
 Absent
 Hypersensitive
 Tested shoulder shrugging (accessory nerve)
1 of 1 point
Observations (1/2 point)
 Symmetric
 Asymmetric
Strength (1/2 point)
 0 – No evidence of movement
 1 – Trace of movement
 2 – Full range of motion with passive movement only
 3 – Full range of motion against gravity, with no resistance
 4 – Full but weak range of motion against gravity, with some resistance
 5 – Full range of motion against gravity, with resistance
Tina Jones Neurological shadow health assessment Objective Data
 Tested neck strength (accessory nerve)
1 of 1 point
Strength (1/1 point)
 0 – No evidence of movement
 1 – Trace of movement
 2 – Full range of motion with passive movement only
 3 – Full range of motion against gravity, with no resistance
 4 – Full but weak range of motion against gravity, with some resistance
 5 – Full range of motion against gravity, with resistance
 Inspected tongue (hypoglossal nerve)
1 of 1 point
Symmetry (1/2 point)
 Symmetric
 Asymmetric
Observations (1/2 point)
 No visible abnormal findings
 Fasciculations
 Deviation from midline
 Atrophy
 Tested deep tendon reflexes in triceps
1 of 1 point
Right (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
Left (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
 Tested deep tendon reflexes in biceps
1 of 1 point
Right (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
Left (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
 Tested deep tendon reflexes in brachioradialis
1 of 1 point
Right (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
Left (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
 Tested deep tendon reflexes in patellar tendon
1 of 1 point
Right (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
Left (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
 Tested deep tendon reflexes in Achilles tendon
1 of 1 point
Right (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
Left (1/2 point)
 0 – No response
 1 – Diminished
 2 – Expected (active)
 3 – Hyperactive
 4 – Hyperactive, with clonus
 Tested point-to-point movements: Finger to nose
1 of 1 point
Right (1/2 point)
 Smooth and accurate
 Jerky
 Inaccurate
Left (1/2 point)
 Smooth and accurate
 Jerky
 Inaccurate
 Tested point-to-point movements: Heel to shin
1 of 1 point
Right (1/2 point)
 Smooth and accurate
 Jerky
 Inaccurate
Left (1/2 point)
 Smooth and accurate
 Jerky
 Inaccurate
 Tested coordination with rapid alternating hand movements
1 of 1 point
Observations (1/1 point)
 Able to perform without difficulty
 Performs but with difficulty
 Unable to perform
 Observed gait
1 of 1 point
Balance (1/2 point)
 Steady
 Unsteady
Gait (1/2 point)
 Continuous, symmetric steps
 Discontinuous steps
 Asymmetric steps
 Stagger
 Swaying
 Hesitancy due to injury
 Use of arms
 Tested graphesthesia
1 of 1 point
Right (1/2 point)
 Able to identify
 Unable to identify
Left (1/2 point)
 Able to identify
 Unable to identify
 Tested sensation in arms
1 of 1 point
Right: Dull Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Left: Dull Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Tina Jones Neurological shadow health assessment Objective Data
Right: Soft Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Left: Soft Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Right: Sharp Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Left: Sharp Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
 Tested sensation in legs
1 of 1 point
Right: Dull Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Tina Jones Neurological shadow health assessment Objective Data
Left: Dull Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Right: Soft Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Left: Soft Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Right: Sharp Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
Left: Sharp Touch (1/6 point)
 Expected sensation in proximal and distal
 Decreased proximal sensation
 Decreased distal sensation
 Tested sensation in feet
1 of 1 point
Right (1/2 point)
 Expected sensation
 Decreased sensation
Left (1/2 point)
 Expected sensation
 Decreased sensation
 Tested position sense
1 of 1 point
Fingers (1/2 point)
 Intact
 Not intact
Toes (1/2 point)
 Intact
 Not intact
 Tested stereognosis
1 of 1 point
Right (1/2 point)
 Able to identify
 Unable to identify
Left (1/2 point)
 Able to identify
 Unable to identify
Tina Jones Neurological shadow health assessment Objective Data