NEUROLOGICAL ASSESSMENT

Neurological Assessment Form

I. Patient Profile

Name of Patient

Age

Sex Select Male Female Other

Ward

Unit

MRD Number

Marital Status

Educational Qualification

Religion

Occupation

Family Income

Address Date of Admission Medical Diagnosis

II. Reason for Hospitalization

III. History of Present Illness

Numbness and Tingling Seizures Headaches Dizziness Sensory Loss Difficulty Speaking Difficulty in Swallowing Muscle Control Memory Loss

IV. Past Health History

Head Injury Loss of Consciousness Sports Injury Accident Meningitis Encephalitis Stroke Spinal Cord Injury

V. Family History

Blood Pressure Stroke Alzheimer’s Disease Epilepsy Brain Cancer

VI. Socio-economic History

VII. Personal History

Prescription Medications Nonprescription Medications Alcohol Recreational Drugs (Marijuana, Tranquilizers, Barbiturates, Cocaine) Smoking

Diet

VIII. Spiritual History

IX. Physical Assessment

1. Head to Foot Assessment 2. General Appearance Select Thin Moderate Built Obese

3. Height (cm)

4. Weight (kg)

5. Head 6. Face Select Symmetrical Asymmetrical 7. Oedema Select Present Absent

Eye

9. Eyebrow Select Equal Distribution of Hair Sparsely Distributed Absent 10. Eyelashes Select Equal Distribution of Hair Sparsely Distributed Absent 11. Conjunctiva Select Pale Yellow Pink 12. Eyelid Select Able to Open & Close Ptosis 13. Pupils Select PERLA Non-Reactive

Ear

15. Position Select Above the Level of Outer Canthus At the Level of Outer Canthus Below the Level of Outer Canthus 16. Drainage Select Present Absent

Nose

17. Nostrils Select Patent Obstructed 18. Septum Select Center Deviated 19. Discharge Select Present Absent

Mouth

21. Lips Select Dry Moist 22. Gums Select Healthy Swollen 23. Odour Select Present Absent 24. Throat Select Normal Inflamed

Neck

26. Trachea Select Midline Deviated 27. Neck Muscle 28. Retraction Select Present Absent

Chest

30. Inspection Select Symmetrical Asymmetrical 31. Auscultation Select S1 S2 Heard Other 32. Lung Sound 33. Percussion Select Hyper Resonant Resonant Dull 34. Palpation

Upper Extremity

36. Range of Motion Select Full Limited

Abdomen

38. Inspection 39. Auscultation Select Absent Borborygmi 40. Percussion Select Tympany Resonant Dull 41. Palpation

Lower Extremity

43. Range of Motion Select Full Limited 44. Capillary Refill Select Less than 3 Seconds More than 3 Seconds

Genitalia

46. External 47. Inflammation/Odor

X. Systematic Assessment

Respiratory System

Observation Auscultation Select Rhonchi Crepitus Wheeze Percussion

Cardiovascular System

Inspection Auscultation Select S1, S2 Murmur Friction Rub Palpation

Gastro-Intestinal System

Inspection Auscultation Percussion Palpation

Musculo-Skeletal System

Range of Motion Select Normal Abnormal

Endocrine System

Endocrine System

Lymphatic System

Lymphatic System

Genito-Urinary System

Genito-Urinary System

Integumentary System

Integumentary System

Central Nervous System

Level of Consciousness Select Alert Lethargy Obtundation Stupor Coma Technique

Glasgow Coma Scale

Eye Opening Select Spontaneous Opening (4) To Verbal Command (3) To Pain (2) No Response (1) Most Appropriate Verbal Response Select Oriented (5) Confused (4) Inappropriate Words (3) Incoherent (2) No Response (1) Most Integral Motor Response Select Obeys Verbal Commands (6) Localizes Pain (5) Withdraws from Pain (4) Flexion (Decorticate Rigidity) (3) Extension (Decerebrate Rigidity) (2) No Response (1) Total Score (3 to 15)

Respiration Pupils Ocular Movement Oculocephalic Reflex (Doll’s Eye Movement) Oculovestibular Reflex Posture and Muscle Tone

Mental Status

Level of Alertness Appropriateness of Responses Orientation to Date and Place

Cranial Nerves

Sense of Smell (I) Visual Acuity (II) Pupillary Reactions (II, III) Extra Ocular Movements (III, IV, VI) Corneal Reflexes, Facial Sensation, and Jaw Movement (V) Facial Movements (VII) Hearing (VIII) Swallowing and Rise of Palate, Gag Reflex (IX, X) Voice and Speech (V, VII, X, XII) Shoulder and Neck Movements (XI) Tongue Symmetry and Position (XII)

Motor System

Body Position Involuntary Movements

Tremors Tics or Fasciculations

Muscle Bulk

Atrophy (Hands) Hypothenar

Muscle Tone

Muscle Strength

Scale for Muscle Strength (0-5) Select 0 – No Muscular Contraction 1 – Barely Detectable Flicker 2 – Active Movement, Gravity Eliminated 3 – Active Movement Against Gravity 4 – Active Movement Against Gravity and Resistance 5 – Normal Muscle Strength Flexion at Elbow Select Normal Abnormal Extension at Elbow Select Normal Abnormal Extension at Wrist Select Normal Abnormal Test of Grip Select Normal Abnormal Finger Abduction Select Normal Abnormal Opposition of the Thumb Select Normal Abnormal Flexion of Hip Select Normal Abnormal Extension of the Knee Select Normal Abnormal Flexion at the Knee Select Normal Abnormal Dorsiflexion at the Ankle Select Normal Abnormal Plantar Flexion at the Ankle Select Normal Abnormal

Coordination

Rapid Alternating Movements Select Normal Abnormal Point to Point Movements Select Normal Abnormal Arms: Finger-to-Nose Test Select Normal Abnormal Legs: Heel-to-Shin Test Select Normal Abnormal

Gait

Walk Across the Room Select Normal Abnormal Walk Heel-to-Toe Select Normal Abnormal Walk on Toes, Then on Heels Select Normal Abnormal Rising from a Sitting Position Select Normal Abnormal

Stance

The Romberg Test Select Normal Abnormal Pronator Drift Test Select Normal Abnormal

Sensory System

Pain Temperature Light Touch Vibration Proprioception (Position) Discriminative Sensations

Stereognosis Number Identification (Graphesthesia) Two-Point Discrimination Point Localization Extinction

Dermatomes

Deep Tendon Reflexes

Scale for Grading Reflexes (0-4+) Select 4+ – Very Brisk, Hyperactive with Clonus 3+ – Brisker than Average 2+ – Average, Normal 1+ – Somewhat Diminished 0 – No Response Biceps Reflex (C5, C6) Select Present Absent Triceps Reflex Select Present Absent Supinator or Brachioradialis Reflex Select Present Absent Knee Reflex Select Present Absent Ankle Reflex Select Present Absent

Cutaneous Stimulation Reflexes

Abdominal Reflexes Select Present Absent Plantar Response Select Present Absent

Special Techniques

Meningeal Sign Select Present Absent Neck Mobility Brudzinski Sign Select Present Absent Kernig’s Sign Select Present Absent

XI. Vital Signs

Temperature (°C)

Pulse (bpm)

Respiration Rate (breaths/min)

Blood Pressure (mmHg)

Nutritional Assessment

A. Diet History

Follows Particular Diet Likes All Foods, Especially Sweets Strong Cravings Late at Night for Chocolate & Ice Cream Eats Fast Food Breakfast 9 AM Dines at Fancy Restaurants 2-3x per Week Has Small Refrigerator on House Boat Occasional Heartburn Especially After Fatty Food Gained 30 lbs in Past Year

Food Intake History (24-Hour Recall)

B. Anthropometric Measurements

Height (cm)

Weight (kg)

BMI

BMI Category Select Normal (20–25) Overweight (25–29.9) Obese Class I (30–34.9) Moderately Obese Class II (35–39.9) Extremely Obese Class III (>40) Ideal Body Weight (%) Obesity Level Select Mild Obesity (20–40%) Moderate Obesity (40–100%) Morbid Obesity (>100%) Waist-Hip Ratio

C. Laboratory Data

Hematocrit (%)

Hemoglobin (gm/dl)

Lipids

Cholesterol HDL LDL Triglyceride Total Lymphocyte Count (cells/mm³) Albumin (g/dl) Glucose (mg/dl) Creatinine (mg %) Nitrogen Balance

Other Investigations

CT MRI EEG