Assess and Document on Neurological System
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Assess and Document on Neurological System
A neurological exam is done to assess the nervous system. It involves examining both the peripheral nervous system and the central nervous system. Neurological diseases present with varied symptoms from headache to limb paraesthesia. The neurological examination begins with collecting subjective data about any neurological complaint. This essay presents a neurological assessment I conducted on my friend.
Subjective Data
The patient denies any history of losing consciousness or confusion. He also denies any recent episodes of headaches and visual problems. The patient also denies any problem with gait or problems with hearing. The patient denies any loss of smell and hearing, or tinnitus. Additionally, he denies any problems with swallowing or speech problems. The patient denies any history of head injury or seizures.
Objective Data
The patient is oriented in time, place, and person. He has dressed appropriately for the weather and setting. The head is of standard shape and size with no scars or marks on inspection. The patient does not have hand tremors. The cranial nerves are all intact. The patient has a score of 40/40 when examined using the Snellen chart. The field of vision is normal and equal in both eyes. The and equally to light. The patient can clench teeth to indicate a normal trigeminal nerve exam. The patient has a normal gait on walking. On the gross motor, the patient has a normal muscle bulk. The upper and lower limbs have normal tone, strength, and power in the right and left limbs. The of the ankle joint, knee, and biceps are intact. The a normal plantar flexion. The patient can coordinate the .
Conclusion
The assessment revealed a normal examination. The pertinent subjective data is normal. Moreover, the objective data is also consistent with a normal neurological exam. Further diagnostics are not recommended because the patient has a normal neurological assessment.
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