8/13/2019 Neurological Assessment.transverse Myelitis
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NEUROLOGICAL ASSESSMENT
CN I (Olfactory) The client correctly identifies scent presented
to each nostril.
CN II (Optic) Client is not having difficulty in reading the
snellen chart and with 20/20
vision OD and OS.CN III (Oculomotor), IV (Trochlear),
VI (Abducens)
The pupil size is about 2-3mm PERRLA. The client was able to
follow eye
movement through the six cardinal fields of gaze. The clients
pupil
opposite the one illuminated constricts simultaneously.
CN V (Trigeminal) Clients temporal and masseter muscles contract
bilaterally. The client
correctly identifies sharp and dull stimuli and light touch to
the forehead,
cheeks and chin. The eyelids blink bilaterally.
CN VII (Facial) The client can smile, frown, wrinkle her
forehead, puffs out checks,
purses lips and closes eyes against resistance. She is using
dentures in her
upper teeth. She is not having difficulty in tasting.
CN VIII (Acoustic/Vestibulocochlear) Client is with intact
hearing. Vibration was heard equally well in both
ears.CN IX (Glossopharyngeal) and X
(Vagus)
The client uvula and soft palate rise bilaterally and
symmetrically on
phonation.Her gag reflex is intact. The client does not have
difficulty
swallowing.
CN XI (Spinal Accessory) Client can contract voluntarily the
sternocleidomastoid and trapezius
muscles.
CN XII (Hypoglossal) The clients tongue movement is symmetric
and smooth and bilateral
strength is apparent.
REFLEXES 2+ biceps and triceps
1+ Patellar and Plantar
COORDINATION Client cant stand due to loss of muscle strength in
lower extremities
MOTOR Client was able to do supination and pronation.SENSORY
Client was able to identify sharp and dull sensation and was able
to
identify objects when closed eyes.
Level of Consciousness
Concentration
Recent & Remote Memory
The client is alert, aware of self, others, time and coherent
with eyes
open and looking at examiner. The client responds
appropriately.
Client listens and can follow direction without difficulty.
The client recalls recent events without difficulty. Client
correctly recalls
past events.
Posture and Body Movements The client appears to be weak in her
lower extremities.
Dress, Grooming and Hygiene Skin is with tatoos; nails are not
neat and trim. Clothes fit and are
appropriate for the weather.
Facial Expression Client maintains good eye contact, smiles and
frowns appropriately.
Speech Client is in a moderate tone and observed to have a clear
speech.
Mood, Feelings and Expressions The client is cooperative and
friendly, expresses her feelings but with
despairing feelings.
