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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 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

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