NEUROLOGICAL ASSESSMENT Level of Consciousness The client is alert, aware of self, others, time, home address and coherent

with eyes open and looking at examiner. The client responds appropriately. Client listens and can follow direction without difficulty. The client recalls recent events without difficulty. Client correctly recalls past events.

Concentration Recent & Remote Memory

The client appears to be relaxed with shoulders and back erect when sitting. Dress, Grooming and Hygiene Skin is clean; nails are neat and trim. Clothes fit and are appropriate for the weather. Facial Expression Client maintains good eye contact, smiles and frowns appropriately. Speech Client is in a moderate tone and observed to have slowed speech with difficulty in articulating but fairly clear meaning. Mood, Feelings and Expressions The client is cooperative and friendly, expresses her feelings but with despairing feelings. CN I (Olfactory) The client correctly identifies scent presented to each nostril. CN II (Optic) Client is having difficulty in reading the snellen chart and wearing eyeglasses and with 130/130 vision OD and OS. CN III (Oculomotor), IV (Trochlear), VI The eyelid covers about 2mm of the iris. The client has limited eye (Abducens) movement though the six cardinal fields of gaze. Bilateral illuminated pupils constrict simultaneously. The clients pupil opposite the one illuminated constricts simultaneously. CN V (Trigeminal) Clients temporal and masseter muscles contract bilaterally. The client correctly identifies sharp and dull stimuli and light touch to the forehead, cheeks and chin. The eyelids blink bilaterally. CN VII (Facial) The client can smile, frown, wrinkle her forehead, puffs out checks, purses lips and closes eyes against resistance. She is using dentures in both teeth. She is having difficulty in tasting. CN VIII (Acoustic/Vestibulocochlear) Client is having difficulty in whispered words from 1 to 2 feet. Vibration was not heard equally well in both ears. CN IX (Glossopharyngeal) and X The client uvula and soft palate rise bilaterally and symmetrically on (Vagus) phonation. Her gag reflex is intact. The client does not have difficulty swallowing. CN XI (Spinal Accessory) Client is symmetric, strong contraction of the trapezius muscle. CN XII (Hypoglossal) The clients tongue movement is symmetric and smooth and bilateral strength is apparent. REFLEXES 2+ deep tendon reflex, biceps, triceps 1+ Achilles reflex COORDINATION Client is having difficulty in balancing and having tendency to fall.

Posture and Body Movements