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. Concentration The client recalls recent events without difficulty. Client correctly recalls past events. Recent & Remote Memory GLASGOW COMA SCALE Eye Opening 4 ; Spontaneous open with blinking at baseline Verbal Response- 5 ; Oriented Motor Response- 6; Obeys commands for movement TOTAL = 15 (NORMAL ) Client correctly differentiates between dull and sharp sensations over various body parts

SENSORY MOTROR

Muscle strength of 3/5 in upper and lower extremities (left), 0/5 in upper and lower extremities (right).Client is having incomplete spinal cord injury.
2+ in left side of biceps and triceps, 0 in right side 4+ in left side of Achilles tendon reflex, 0 in the right side 1+ in left side of plantar reflex, 0 in the right side The client correctly identifies scent presented to each nostril. Clients vision is normal. The eyelid covers about 2mm of the iris. The client has limited eye movement though the six cardinal fields of gaze. Bilateral illuminated pupils constrict simultaneously. The clients pupil opposite the one illuminated constricts simultaneously. 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. The client can smile, frown, wrinkle her forehead, puffs out checks, purses lips and closes eyes against resistance. No difficulty in hearing. Vibration was heard equally well in both ears. The client uvula and soft palate rise bilaterally and symmetrically on phonation. Her gag reflex is intact. The client does not have difficulty swallowing. Client is asymmetric, weak contraction of the trapezius muscle. The clients tongue movement is symmetric and smooth and bilateral strength is apparent.

REFLEXES

CN I (Olfactory) CN II (Optic) CN III (Oculomotor), IV (Trochlear), VI (Abducens)

CN V (Trigeminal)

CN VII (Facial) CN VIII (Acoustic/Vestibulocochlear) CN IX (Glossopharyngeal) and X (Vagus)

CN XI (Spinal Accessory) CN XII (Hypoglossal)