Tina Jones Neurological 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)

■ 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) Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

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