a

Neurological Assessment

come on in washing my hands

hi mr. Ruffman I'm Nancy I'm a nurse

from Harper College how are you doing

very well thank you good I'm here today

to do a neurological assessment and I'm

going to start off the assessment by

asking you two questions

have you ever had a stroke no okay good

good

and do you have any other problems with

your coordination or with your brain

that you're aware of

don't ever get meningitis or MS No all

right all right good okay that's good to

know

so as we do this I'm going to start by

checking all of your cranial nerves and

then we're going to check your

coordination and then we're going to

check sensation and

we're going to do some deep tendon

reflexes so we'll start out by just

talking with you and we're doing what's

called a mental state

so I'm first often noticing your

behavior you're a week and alert and

cooperative and responding well and then

I'm also noticing your cognition so I'm

going to ask you some kind of slight

questions good so can you tell me what

month it is this is the month of August

okay now that's correct

and can you tell me who your favorite

president is he's dead but it was

President Ronald Reagan not happy to

know the answer to this question so I

know that's correct but who's the

current president ooh that's a tough one

Obama Obama is the current president

exactly and can you tell me who I am yes

Nancy character okay good so he is

oriented to person place in time and

tell me why you're here today well I'm

here today to be checked out of and

we're doing videos for the assessment

courses at Harper okay someone he is

also aware of the situation so he's

great at times four person place time

and situation and I am also noticing

that his dress is appropriate his effect

is appropriate his facial expression is

all appropriate for the situation I also

need to screen him for depression and

suicidal thoughts this is a screening

that's done at every health care

today it's required by the state of

Illinois because suicide is a high

causes a high rate of death here in our

state so sir have you ever been so blue

that you felt like hurting yourself

no have you felt depressed or unhappy

lately over the past two weeks my or

Mike - these are not fun no I've been

having fun okay all right so at that

point I can stop my assessment if he

answered yes to any of those questions

and I would probe further with more

questions about that so but he had took

know for the first screen and then we're

done

all right so we're going to move on for

the cranial nerves I'm going to start

with cranial nerve number two and that

is - we are visual acuity so we checked

your visual acuity today and we would

check it for this assessment as well

using the snow in art I charge standing

20 feet away we would check both your

right and your left eye and your vision

was 2025 in both eyes and continuing on

with cranial nerve number two we would

do a confrontation test can you stand up

and using this card can you place this

over your left eye

and then I will place this over my eye

and tell me when you see my fingers I

see them

yes

yes

yes okay this

straight at me tell me when you see my

fingers yes

yes

yes

yes okay good your peripheral vision is

intact

that's cranial nerve number two have a

seat now we're going to check cranial

nerves number three four and six can you

take your glasses off you can just hold

on to me for a second and I want you to

follow this pen in the six cardinal

positions of gaze keeping your head

straight and I see conjugate movement of

my eyes together in six cardinal

positions of gaze

right and just follow this I'm going to

bring it in towards your nose nice

good accommodation and then I'm going to

look in your people going to shine a

light in and I see that the pupils both

of them respond to light by constricting

and I would document that as pearl

pupils are equal round reactive to light

and accommodation as cranial nerves

number three four and six and then

moving on to cranial nerve number five

number five in sensation where we are

going to look at some movement of your

face that can you smile and frown and

show your teeth plate and I'm just going

to check the muscles here so you hurt

your teeth and I can feel those muscles

get nice and tight they're relaxed and

then also there is a sensory portion to

this cranial nerve so can you close your

eyes tell me when you feel the cotton

whiz say now

well well wonderful all right open your

eyes again

moving on to cranial nerve number six we

are it is we're going to move on to

cranial nerve number seven and can you

lift your eyebrows up and down and then

smile and frown it can squeak your eyes

closed real tight and then open them all

right I'm looking for symmetry of the

face I remember with this cranial nerve

damage is it Bell's palsy where you

would see goofy on one side of the face

or you might see that with a stroke so

that's cranial nerve number seven

cranial nerve number eight is the

acoustic I'm going to whisper something

in your ear I want you to repeat it

green wall

the Cubs are going to win call her

rights all his acoustic nerve is intact

you can put your glasses back on so that

was cranial nerve number eight and then

moving on for cranial nerve number nine

and ten can you open your mouth really

wide and say ah wonderful and I see his

uvula goes up and the soft palate goes

document indicates that cranial nerve

number nine and ten is in 10 and then

cranial nerve number eleven can you turn

against my hand and turn against my hand

and shrug up against my hand

and cranial nerve number 11 is intact

and then cranial nerve number 12 can you

stick your tongue out and the tongue

should be in the midline which it is so

now we're going to check muscle strength

so we'll start with the upper

extremities can you please hold your

hands out like this and we would do that

for a count of ten and then can you

squeeze my fingers please as hard as you

can squeeze really hard hard as you can

around you're not going to hurt me

all right good okay so the reason that

we tack strength in this manner for a

neurological assessment is that this arm

lift is part of the NIH Stroke Scale

that's used across the nation for our

assessment of stroke and doing the

finger finger squeeze is an easy way to

check assessment of strength of the

upper extremities if you give two

fingers the person can squeeze as hard

as they want they're not going to hurt

you if you give your whole hand or you

give three fingers you may come back

with your fingers like that which is

usually not very pleasant and then for

the lower extremities on heavy lay back

for a minute

to probably want to lay back and I want

to lift this leg up off the bet and we

do that for a count of five one two

three four five good and then lift this

one up again to account a five one two

three four five and relax again that is

part of the NIH Stroke Scale that's why

we use that method and then if you can

press down against my hands and pull up

against my hands that also tells

strength of the lower extremities okay

so from there we're going to do some

tests of your coordination so can you do

this if you touch your for each finger

as quickly as you can

and do with the other hand

all right good and now touch your nose

and then touch my finger both as quickly

as you can

all right that's good one caution while

you're doing this is that when your

client has their their finger to the

nose okay at that time you can move it

but don't as they start for your finger

don't move it right at that time all

right that's not a fair test then so you

can move it while the fingers there but

then hold still as soon as they start

coming towards your finger so we're

going to check coordination of the lower

extremities - so can you take your shin

and just end your kill just run it down

your shin and then do it out of this

other side just run it right straight

down all right and then can you stand up

for a moment

going to do the Romberg's

test put your feet together and put your

hands at your stand up straight put your

hands at your side put your hands at

your side and close your eyes and we

would count to 20 seconds and he should

be able to maintain the standing

straight and still without falling over

make sure you're here just in case a

person does start to lose balance so I

don't get hurt so 1-10 11-20 very good

you can open your eyes and

can you walk like a couple steps towards

that outlet there just like about three

or four steps just normal and then come

back and walk heel to toe heel to toe

like this

you can relax your arms

okay good fantastic so your coordination

and is intact and then we're going to

check the sensory system so the first

thing that I'm going to do is check your

sharp dull discrimination so you start

this fight you have in your eyes open

and explaining this is sharp and this is

dull you can use a paper clip that

you've opened up you can also use a

cotton swab to do this whatever you're

comfortable with so close your eyes and

then you're going to tell me whether you

feel sharp or dull and do this all over

so sharp though

sharp

sharp sharp

that was dull

sure cannot drop a lot when you're doing

this sure sharp sharp sharp don't

sure

go all right you can open your eyes

again we're going to check your light

sensation I'm just going to use a cotton

ball and I just want to say now when you

feel that so close your eyes say now

when you feel kind of all now now now

now

now

now-now-now

now

oh all right good

last thing eyes closed and hold out your

hand and tell me what's in your hand you

can feel it with your hand

it's a it's a coin okay good open your

eyes

all right so let's offer our testing of

sensation now we're going to move on to

the deep tendon reflexes so start this

by having you just relax your arm here

all right I want to be really really

really asked for this to work and you

can talk to Amy over there by your

wellness my half the way I'm going to do

this is Kevin flex a little bit so I can

find that tendon and then he have him

relax you really have to be relaxed to

this will not work you also have to hold

pressure on the tendon pretty firmly and

see my thumb is on there pretty firm use

the pointy part of the reflex hammer and

you have to give it a good whack and I

could feel his tendon moving I'm going

to looking for is where his fingers to

which I did not see there we go now we

saw it a little bit there okay and then

we were do the same thing on the other

side

again I'm going on flex so that I can

feel where that tendon is I'm going to

hold it pretty firmly now I have very

poor aim to do it with my other hand but

if you can hit your thumb with your left

hand that would be lovely

I'm not too good at that okay so relax

your hand

talk to EB over there hello hold it

firmly and what I'm looking for there we

go it's for those fingers to me so they

haven't tends to be a little bit

stubborn sometimes

when you're trying to do that it's

important for the person to relax then

we're going to move on to the patellar

reflex okay so you're going to feel

where that B camp is and then right

below there is where you're going ken

you want the person to be really relaxed

when you hit you know on a hit like this

one hit loosely like that when you hit

it bounces off

right so you should be able to

little kick

from doing that which doesn't seem to be

working well with

be relaxed

yes after you sir oh well we got a

little one there okay

okay okay into our Lancer all right one

more time yeah be careful that you don't

get kicked in the thing okay lay back

down for a second that's the way I'm

going to get my I'm going to get my

payback right now

last thing is the baboon side reflex

okay so you're going to draw J up the

side of the foot and across the sole of

the foot normal response for an adult is

curling of the toes so draw up the foot

and across so either no response or

curling up the coast is normal a normal

response is a fanning out of the toes

and reflection of the great toe that

would be an abnormal response so a

negative is normal just like if you get

an x-ray and it's negative that's normal

so negative is curling up the toes okay

like that a positive Babinski is bad and

that's the Fanning and flexing off the

toes okay I think that we are done with

our

call assessment