NEUROLOGICAL ASSESSMENT CASE-SHEET

DEMOGRAPHIC STATUS-
NAME
AGE/SEX
OCCUPATION
ADDRESS
MARITAL STATUS

CHIEF COMPLAINT (WITH DURATION)

HISTORY
PRESENT ILLNESS

PAIN HISTORY-
 Onset
 Site
 Duration
 Type
 Nature
 Radiation
 Aggravating factor
 Relieving factor

PAST HISTORY-
 Convulsions
 Meningitis
 Infection
 Encephalitis
 Pneumonia
 Jaundice
 Trauma/ accident
 Hemorrhage
 General developmental delay
 Malnutrition

FAMILY HISTORY-
  Consanguinity
 Epilepsy
 Disability
 Cardiovascular disorders
 Inflammation
 Rh factor

SOCIO-ECONOMIC HISTORY-
 Education
 Occupation/ career
 Tobacco
 Cigarette
 Alcohol

MEDICAL HISTORY-
 Drug/allergy

SURGICAL HISTORY-
 Incision
 Length
 Duration
 Procedure

PHYSIOTHERAPY TREATMANT-
 Aims
 Treatment

ON OBSERVATION

GENERAL

BUILT
POSTURE:
1. ANTERIOR VIEW
 Head position
 Ear level
 Shoulder level
  Nipple level
 ASIS level
 Knee level
 Ankle level

2. POSTERIOR VIEW
 Head position
 Scapula level
 Spinal curves
 Cervical
 Thoracic
 Lumber
 PSIS level
 Popliteal fossa
 Heels

3. LATERAL VIEW
 Ear level
 Shoulder level
 Cervical lordosis
 Thoracic kyphosis
 Pelvic tilt
 Knee level
 Ankle level

GAIT
1. Starting position
2. Arm swing
3. Swing phase
4. Stance phase
5. Any aid
6. Any deviation

DEFORMITY
EXTERNAL APPLIANCES

LOCAL:
FACIAL EXPRESSION
OEDEMA
COLOUR
ATROPHY
SCAR/ INCISION/ WOUND
CYANOSIS
CLUBBING
NEUROLOGICAL GRAFTS
BREATHING TYPE
EYE MOVEMENT
DRAINS
VENTILLATORS
FLUID INTAKE/ OUTPUT

INSTRUMENTATION:-
 Monitoring
 Catheterization
 Ryle’s tube
 Tracheostomy

MOTOR SYSTEM

 APPEARANCE
 Asymmetry/ deformity
 Muscle wasting
 Hypertrophy
 Fasciculation
 Myokimia

 CONGENITAL DEFORMITY
 INVOLUNTRY MOVEMENTS-

 Chorea
 Dystonia
 Athetosis
 Tremors
 Hemi ballismus
  Clonus

ON PALPATION
 TEXTURE: DRY SKIN/ SCALY/ SMOOTH
 WARMTH
 SCAR: ADHESIVE/ NON-ADHESIVE
 TYPE OF OEDEMA: PITTING/ NON-PITTING
 SPASM/TIGHTNESS/ CONTRACTURE
 DEFORMITY: RIGID/ FLEXIBLE
 TONE: HYPOTONICITY/ HYPERTONICITY/ISOTONICITY
 SWELLING: SESSILE/ PENDUNCULATED
 ANTERIOR: FRONTELL

ON EXAMINATION

1. GENERAL

A. VITAL SIGNS

 BP
 TEMP
 RESP RATE
 HEART RATE

B. HIGHER CORTICAL ASSESSMENT

 GLASGOW COMA SCALE
 eye opening
 verbal response
 motor response
 COGNITIVE SCALE
 MMSE
 RLA

 BEHAVIOURAL ASSESSMENT
  PERCEPTUAL ASSESSMENT

C. INTELLECTUAL FUNCTION
 ORIENTATION
 MEMORY
 LEVEL OF INTELLEGENCE
 EMOTIONAL STATUS
 PERSONALITY TYPE
 SLOWNESS OF MOVEMENT
 SPEECH
- articulation
- aphasia

 MEMORY
- STM
- LTM
- RECENT
- REMOTE

2. CRANIAL NERVE EXAMINATION

a) OLFACTORY NERVE-
 Anosmia
 Parosmia

b) OPTIC NERVE-

 Visual acuity
 Visual field
 Pupil- same eye/ opp eye

c) OCCULOMOTOR NERVE/ TROCHLEAR/ ABDUCENS-

  PUPIL- same eye/ opp eye.
 PTOSIS- right/ left
 OCCULAR MOVEMENT- Upward movement
Downward
Lateral
Medial
Upward and outward
Upward and inward
Downward and outward
Downward and inward
 CONJUGATE MOVEMENT- same eye/ opp eye
 NYSTAGMUS- right/left

d) TRIGEMINAL NERVE-
 CORNEAL REFLEX
 MOTOR EXAMINATION- chewing and clenching
 JAW REFLEX
 SESNSORY EXAMINATION- Ophthalmic area
Maxillary area
Mandibular area

e) FACIAL NERVE-
 MOTOR EXAMINATAION
- blinking
- blowing
- frowning
- smiling
- raising of eye brow
 SENSORY EXAMINATION
- temporal area
- ophthalmic area
- maxillary area
- mandibular area
- cervical area
 TASTE EXAMINATION
- anterior 2/3rd of tongue
 f) AUDITORY NERVE
 WEBER TEST- conduction defect / neural defect
 RINNE’S TEST- conduction defect/ neural defect
 VESTIBULAR TEST- Caloric test
Hall pike test

g) GLOSSOPHARANGEAL NERVE
 Gag reflex
 Ah response
 Ugh response
 Taste on posterior 1/3rd of tongue

h) VAGUS NERVE
 Palatal movement

i) ACCESSORY NERVE
 SCM
 TRAPEZIUS

j) HYPOGLOSSAL NERVE
 TONGUE MOVEMENT
 ATROPHY
 TONGUE DEVIATION

3) SENSORY EXAMINATION
a) SUPERFECIAL SENSATION
 Touch
 Temp
 Pressure
b) DEEP SENSATION
 Vibration
 2-point discrimination
 Proprioception

4) MOTOR SYSTEM

a) MUSCLE TONE
b) TONICITY- hypotonic/ hypertonic/ isotonic
c) MMT-

1. SHOULDER
RIGHT LEFT
a. flexor
b. extensor
c. abductor
d. adductor
e. internal rotation
f. external rotation

2. ELBOW
a. flexor
b. extensor
c. supinator
d. pronater

3. WRIST
a. flexor
b. extensor
c. ulnar deviation
d. radial deviation

4. FINGERS
I. Fingers
a. flexor
b. extensor
c. abductor
d. adductor
e. opponens
II. Thumb
a. flexor
b. extensor
c. abductor
d. adductor
e. opponens
5. HIP
a. flexor
b. extensor
 c. abductor
d. adductor
e. internal rotation
f. external rotation

6. KNEE
a. flexor
b. extensor

7. ANKLE
a. flexor
b. extensor

8. TOES
a. flexor
b. extensor
c. abductor
d. adductor

5. MEASUREMENT:
CIRCUMFERENCE-
 Thigh
 Calf
 Arm
 Forearm

LIMB LENGTH MEASUREMENT

 True
 Apparent
 Segmental
- femur
- tibia
6. JOINT ROM

I. SHOULDER
RIGHT LEFT
a. flexor
b. extensor
c. abductor
 d. adductor
e. internal rotation
f. external rotation

II ELBOW
g. flexor
h. extensor
i. supinator
j. pronater

III WRIST
k. flexor
l. extensor
m. ulnar deviation
n. radial deviation

IV FINGERS
I. Fingers
a. flexor
b. extensor
c. abductor
d. adductor
e. opponens
II. Thumb
a. flexor
b. extensor
c. abductor
d. adductor
e. opponens
V. HIP
a. flexor
b. extensor
c. abductor
d. adductor
e. internal rotation
f. external rotation

VI . KNEE
a. flexor
o. extensor
 VII. ANKLE
a. flexor
b. extensor

VIII TOES
a. flexor
b. extensor
c. abductor
d. adductor

7. DEEP TENDON REFLEXES-

 Biceps
 Triceps
 Brachioradialis
 Quadriceps
 Hamstrings
 Tendo-achillis

8. SUPERFICIAL REFLEX-
a. Abdominal- diminished / normal / exaggerated
b. Planter/ babinki’s sign

9. COORDINATION
- Equilibrium test
- Non-equilibrium test

10. BALANCE-
- Static
- Dynamic
( Berg balance scale)

11. FUNCTIONAL ASSESSMENT (F.I.M. SCALE)

 Dressing
 Feeding
 Toileting
 Transfer
  Combing
 Gait
 Brushing

12. BOWEL AND BLADDER-

 Uninhibited
 Atonic
 Autonomous
 Motor
 Sensory

13. GAIT
(G.A.R.S.SCALE)

14. CASE SHEET STUDY

15. INVESTIGATION
 X-RAY
 CT SCANE
 MRI
 CSF
 BLOOD TEST

PROVISIONAL DIAGNOSIS