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)

WE ARE THE SHADOW HEALTH EXPERTS,

CHAT US TO PLACE OUR ORDER AND SCORE 100%

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)