Clinical Tasks Submitted by: Placido, Genicel D. Section: BSNIII A-02 Case No.

021311-A Date Examined: January 24, 2010 1. Neurological Assessment: Complete a neurological assessment on an assigned patient. Note
any abnormalities

Assessment and Findings Cerebral Function 1. Overall appearance, behavior, psychomotor activity, attitude towards the examiner. Patient assumes a slouching position while sitting and standing. Patient doesnt really care of her hygiene, patient wears her clothes repeatedly. Patient is always breathless. Patient was lethargic. The patient is drowsy but awakens upon stimulation. She answered questions and follow commands, but will do so slowly and inattentively Patient exhibits a sad affect most of the time. Patient has slow rate of speech and doesnt have blanks in speech. Patient also has normal rate and production of speech. Patient has coherency and relevance of thought processes. Patient has no phobias, obsessions, and has mild anxiety. Patient is able to recall brief retention, recent and remote memory. Patient has limited vocabulary, only uses tagalong Patient was able to reason out the questions we asked Has poor judgement We werent able to test her for sensory perception and coordination, patient was too weak to do writting activities, and can stand and walk with assistance. Has decreased sensitivity to smell Client can see from a distance of 20 feet away what is normally visible from 30 feet away on both eyes

2. level of consciousness

3. mood and affect 4. Speech

5. thought process and perception

6. Cognitive function o Memory o Vocabulary o Abstract reasoning o Similarities o Judgment o Sensory Perception and coordination

Cranial Nerve 1. CN#1 : Olfactory 2. CN#2: Optic

3. CN#3, 4, 6: Oculomotor, Trochlear and abducens 4. CN#5: Trigeminal 5. CN#7: Facial 6. CN#8: Acoustic 7. CN#9, 10: Glosoopharyngeal and Vagus Nerve 9. CN#11: Spinal Accessory Nerve 10. CN#12: Hypoglossal Motor System 1. Assessment of Muscle Tone 2. testing Muscle Strength Sensory System 1. Pain 2. Temperature 3. Light Touch 4. Vibration 5. Position Discriminative sensations: 1. Number Identification 2. Two- Point Discrimination 3. Point Localization 4. Extinction Reflexes Deep Reflexes 1. Biceps 2. Brachioradialis 3. Triceps 4. Pattelar 5. Achilles Superficial Reflexes 1. upper abdominal 2. Lower Abdominal 3. Cremasteric 4. Plantar 5. Gluteal 6. Babinski Cerebellar Function 1. Gait

gaze and six ocular movements Senses are sensitive and intact. But too weak to clench teeth. Loss of sense of taste. Symmetrical facial expression. patient can hear words and whispered words gag reflex not performed, swallowing ability and tongue movements are normal. Patient can weakly shrug shoulders Patient can protrude tongue Patient has poor muscle tone and very weak muscle strength Patient can perceive pain when pricked by a needle Can perceive temperature Cant fully perceive light touch sensations Wasnt able to perform Patient can distinguish to what position her fingers are pointed

Has poor discriminative sensations

all deep reflexes are elicited with use of reflex hammer Both right and left bicep reflexes were active Both right and left brachiradialis reflexes were active Both right and left tricep reflexes were active Both right and left patellar reflexes were active Both right and left achilles reflexes were active

Wasnt able to perform Reflex is slightly present. Wasnt able to perform Result was negative patient has slouching posture and unsteady gait

2. Rombergs Test 3. Pronator Drift Coordination in the Arms: 1. Rapid Rhythmic Alternating Movement 2. Point to Point Testing

sways slightly but able to maintain balance with assistance Patient can perform pronator drift with assistance in balance Can do it but in slow motions Patient has slight awkwardness performing the point to point test.

Coordination in the Legs: 1. Rapid Rhythmic Alternating Movement 2. Point to Point Testing

Patient can do it but in slow motions and with assistance Patient has slight awkwardness performing the point to point test.

2. Discuss neurological tests completed on patient on the clinical unit. Distinguish the reasons for the tests and any diagnoses made. Patient was diagnosed with PTB3. Patient was very thin when the assessment was done, she was very weak. She cannot get out of bed alone, she calls us for assistance. She cant walk far enough to go to the comfort room, so she was given a bed pan instead.