Topics

• Musculoskeletal
• Neurological
• Screening and Health Promotion
• Pediatric Variations

NDNP 819: Advanced Health Assessment Across the Lifespan

Module: Musculoskeletal

Neurological

History

It is important to ask ROS clues and for associated symptoms in assessing neurological complaints. Weight loss and appetite changes can be general indicators of neurological problems but are vague symptoms also associated with other disease processes. Fatigue, depression, headache are additional, nonspecific symptoms of possible neurological pathology. Fever and or chills are often evidence of an infection and the presence of stiffness, photophobia and headache may be signs of an intracranial bleed or infection such as meningitis. Diabetic individuals experience peripheral neuropathy and associate pain that occurs at rest or at night and/or progressive pain in their history. The examiner should inquire about a history of headaches? head injuries? dizziness/vertigo? seizures? tremors? weakness? uncoordinated movements? numbness or tingling? difficulty swallowing? difficulty speaking?

For PMH the provider should inquire if the patient has ever had:

1. Meningitis/encephalitis
2. Stroke
3. Disk disorders
4. Neck/back Surgeries
5. Cancer History
6. Smoking
7. HTN
8. Head or spine injuries
9. IV drug use
10. Alcoholism
11. Surgery/instrumentation
12. Trauma esp. penetrating
13. Bacterial infections

Physical Exam

The keys point of the neurological physical exam are to initiate your exam the moment you introduce yourself to the patient. Watch the patient walk and move around (best if can do when they don’t know you’re watching). Note general appearance and handedness before formally examining: Pupils, Cranial nerves, Sensory testing, Cerebellar functioning/balance, Strength, Abnormal movements, Rigidity & Reflexes/DTRs.

Deep Tendon Reflexes are also known as the ‘stretch reflexes’, DTR’s reveals the intactness of the reflex arc at specific spinal levels. The limb should be relaxed and the muscle partially stretched. This exam is always performed bilaterally and systematically (head to toe, for example) for ease or comparison and documentation.

Sample Normal Documentation: Neurological

Neurological: Mental Status: Alert and cooperative. Oriented to person, place and time. Cranial Nerves: CN II-XII intact. CN I not tested. Motor: Good muscle bulk and tone. 5/5 strength throughout. Cerebellar: Gait is coordinated and even. Rapid alternating movements coordinated and smooth. Sensory: superficial touch, pain, vibratory sensation are intact bilaterally. Romberg negative. Deep TendonReflexes:2+ bilaterally in all extremities (1+ to 3+ considered normal if symmetric & if no big difference between arms & legs)

How to document Special Neuro Tests.

Sensation:

• sharp/dull sensation intact bilaterally
• vibration sensation intact bilaterally ( see above)
• proprioception intact bilaterally

Discriminative Sensations: To document normal say: “tested without deficit”

• graphesthesia
• point localization

Coordination to document normal say: “preformed without deficit”:

• rapid alternating movements
• point to point
• gait (heel to toe)
• balance (hop on one foot)
• Romberg (document as positive or negative)
• pronator drift

Special Signs: These are documented as positive or negative.

• Brudzinski’s sign
• Kernig’s sign