Rasmussen College Neurological System Physical Assessment

You will perform a history of a neurologic problem that your instructor has provided you or one that you have experienced and perform an assessment of the neurologic system. You will document your subjective and objective findings, identify actual or potential risks,

Documentation of Assessment of the Neurological System
Examiner:
Date:
Patient:
Date of Birth:
Reason for Visit:
Health History
1. Any unsually frequent of severe headaches?
2. Any head injury?
3. Ever feel dizziness?
4. Any history of seizures?
5. Any tremors in the hands or face?
6. Any weakness in specific part of your body?
7. Any problem with coordination?
8. Any numbness or tingling?
9. Any problems swallowing?
10. Any problems speaking?
11. Past history of stroke, spinal cord injury, meningitis, congenital defect, or alcoholism?
Physical Assessment
1. Cranial Nerves
a. CN I
b. CN II
c. CN III, IV, VI
d. CN V
e. CN VII
f. CN VIII
g. CN IX, X
h. CN XI
i. CN XII
2. Motor System
a. Muscle Strength
i. Grip strength
ii. Plantar flexion and dorsiflexion
iii. Involuntary movements noted?
b. Cerebellar Function
i. Rapid alternating movements
ii. Finger to nose test
iii. Heel to shin test
iv. Gait
v. Romberg test
3. Sensory system
a. Sharp and dull test (two areas of arms and legs bilaterally)
b. Position sense on hands and feet
4. Reflexes (both sides and include grade of reflex)
a. Triceps
b. Biceps
c. Brachioradialis
d. Patellar
e. Achilles
f. Plantar
Regional Write-Up
1. Subjective (Health History)
2. Objective (Physical Assessment)
3. Assessment of Risks and Plan