Objective data from Tina Jones’s neurological shadow health assessment
Collecting Objective Data: 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)
- 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 an 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 the dull stimulus
- Unable to feel the sharp stimulus
- Unable to feel the 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)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Left: Dull Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
- Tina Jones Neurological shadow health assessment Objective Data
Right: Soft Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Left: Soft Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Right: Sharp Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Left: Sharp Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Tested sensation in legs
1 of 1 point
Right: Dull Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
- Tina Jones Neurological shadow health assessment Objective Data
Left: Dull Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Right: Soft Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Left: Soft Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Right: Sharp Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Left: Sharp Touch (1/6 point)
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
Tested sensation in feet
1 of 1 point
Right (1/2 point)
- Expected sensation
- Decreased sensation
Left (1/2 point)
- Expected sensation
- Decreased sensation
Tested position sense
1 of 1 point
Fingers (1/2 point)
- Intact
- Not intact
Toes (1/2 point)
- Intact
- Not intact
Tested stereognosis
1 of 1 point
Right (1/2 point)
- Able to identify
- Unable to identify
Left (1/2 point)
- Able to identify
- Unable to identify
- Tina Jones Neurological shadow health assessment Objective Data