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)
  •  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