History of Neurologic disease

History of neurologic disease or disorders (be specific regarding all diseases associated with the CNS system). For example: CVA, TIA, Parkinson Disease, Alzheimer’s and other disease entities that are included in the CNS.

4. Current Neurologic Symptoms:

(a) In motor function: weakness, tic or tremor, paralysis, or balance, coordination problems.

(b) In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation).

C.  In mental status: any nervousness, mood change, depression, or any history of mental health disorders, hallucinations and other conditions.

5. Health Promotion: Alternatively, data about interpersonal relationships; coping patterns placed here. Note any safety concerns such as falls and additional health promotion concerns.

6. Write the medical health history for your subject in a narrative paragraph form. Avoid quoting the clients responses.

A. Select an area of the brain and describe the major function of that component of the CNS. Note how that area is assessed (motor and sensory pathways).

Sensory- Neurological System

 For this section, provide a detailed response of how you would perform the assessment as well as the finding from the physical assessment of your subject. 

A. Assess behavior, note facial expression, posture, affect, and grooming (describe what you see)

B. Determine the level of consciousness (do not abbreviate terms, spell out the words used to report this finding).

C. Assess memory – immediate memory:  repeat a series of 3 numbers in reverse order, remote.

D. Assess calculation skills- simple and more complex calculations, counting backwards from 100, starting at 100 and keep subtracting 3

E. General knowledge, abstract thinking, judgment, communication skills (what questions can you ask the patient to illicit the information?)

Cranial nerve testing:

1. Olfactory I
2. Optic Nerve II
3. Oculomotor, Trochlear, and Abducens Nerves III, IV, and VI
4. Trigeminal Nerve V
5. Facial Nerve VII
6. Acoustic Nerve VIII
7. Glossopharyngeal and Vagus nerves IX and X
8. Accessory Nerve XI
9. Hypoglossal Nerve XII

Test superficial sensations 

1. Test discriminatory sensations (two-point discrimination, graphesthesia and stereogenosis)
2. Observe gait and assess balance- note base of support, phases of gait, Romberg test, walk on heels and then on toes, do a deep knee bend, and hop in place on each foot.
3. Assess coordination – perform finger-thumb opposition, rhythmic toe tapping with each foot, run the heel of one foot against the shin of the opposing leg.

1. Test accuracy of movements- have patient touch his finger to his nose with eyes open and then with eyes closed.
2. Test muscle strength by repeating ROM against resistance for the upper and lower extremities (pedal pushes, pulls and hand grasps).

Grading scale

0= no movement

1= severe weakness, paralysis

2= passive ROM, poor ROM

3=AROM against gravity, weakness

4= AROM against some resistance, slight weakness

5= AROM against full resistance, normal

Deep tendon reflexes 

Grading scale

0= no resistance

+1=diminished response

+2=normal response

+3 somewhat stronger than normal response

+4 hyperactive, involuntary movements that continue after tapping with hammer-clonus

1. Brachioradialis reflex
2. Biceps reflex
3. Triceps reflex
4. Patellar reflex
5. Achilles reflex

Superficial reflexes 

Plantar reflex (Babinski)