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Tina Jones Neurological Objective Data

Tina Jones Neurological Objective Data

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 Tina Jones Neurological Objective Data
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 Tina Jones Neurological Objective Data
 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) Tina Jones Neurological Objective Data
  •  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 Tina Jones Neurological Objective Data
  •  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) Tina Jones Neurological Objective Data
  •  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 Tina Jones Neurological Objective Data
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) Tina Jones Neurological Objective Data
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) Tina Jones Neurological Objective Data
  •  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) Tina Jones Neurological Objective Data
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 Tina Jones Neurological Objective Data
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 Tina Jones Neurological Objective Data
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 Tina Jones Neurological Objective Data
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 Tina Jones Neurological Objective Data
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 Tina Jones Neurological Objective Data
  •  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 Tina Jones Neurological 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) Tina Jones Neurological Objective Data
  •  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) Tina Jones Neurological Objective Data
  •  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