How would the subjective and objective findings

How would the subjective and objective findings of the Neurological assessment be written as a summary? Patient Initials: FB _Age:53 Gender: M I Health History-Subjective Data (yes no answers-all yes answers explain) 1. Any unusually frequent or unusually severe headaches? No, the Client denies any frequent or unusually severe headaches. 2. Ever had a head injury? No 3. Ever feel dizziness? Yes, the client states only when he stands up fast. 4. Ever had any convulsions? No 5. Any tremors in hand or face? No 6. Any weakness in any body part? No 7. Any problem with coordination? No 8. Any numbness or tingling? No 9. Any problem swallowing? No 10. Any problem speaking? No 11. Past history of stroke, spinal cord injury, meningitis, congenital defect, alcoholism? No, the client denies. 12. Any environmental/occupational hazards? No II Physical Examination Muscle System 1. Muscles-size, strength tone- Muscle feels firm, muscle strength is a five in all four extremities: movement is smooth, coordinated, and no pain or difficulty noted during ROM. 2. Involuntary movements-No involuntary movements noted. Cerebellar Function Assessments 1. Gait- Strong 2. Romberg test- Negative 3. Rapid alternative movements- No difficulties noted. 4. Finger-to-finger test-performs with accuracy and rapidity. 5. Finger-to-nose test- follows direction accurately 6. Heel-to-shin test-runs heal smoothly down each shin. Sensory System Assessments-Spinothalamic Tract 1. Pain- able to discriminate sharp and dull sensations 2. Temperature- able to feel warm, cold, and hot. 3. Light touch-light tickling or touch sensation. Sensory System Assessments-Posterior Column Tract 1. Vibration-normal 2. Position (kinesthesia)-normal, moves effortlessly. 3. Tactile discrimination-Stereognosis- able to distinguish, and identify numbers or letters written on the palm. 4. Tactile discrimination-Graphesthesia-able to feel and recognize what is written on. Palm. 5. Two-point discrimination/extinction/point location-able to distinguish Locate and grade reflexes-0=absent, 1+=hypoactive, 2+=normal, 3+=hyperactive +4=hyperactive with clonus Biceps Triceps Brachioradialis Quadriceps Achilles Plantar Right 2+ 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+ 2+ **Plantar reflex**State Normal or Abnormal Response Normal response=flexion of the toes and inversion and flexion of the forefoot Abnormal response except in infancy=dorsiflexion of the big toe and fanning of all toes (which is a positive Babinski Sign, also called “upgoing toes” Review-Neuro Recheck-LOC-Motor Response (hand grasps), Pupillary Response, Vital Signs SCIENCE HEALTH SCIENCE NURSING G 150/PHA 1

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