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Assessment

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Science
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Rasmussen University
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Documentation of Assessment of the Neurological System
Examiner: Susan Blake
Date:
Patient: Noses Mark
Date of Birth: 11. 01.1990
Reason for Visit: Headaches
Health History
The patient has been having severe headaches for about two months. There have been persistent
painkillers, which only relieve him of the pain for a short moment. The patient explains that he
was once involved in an accident as he played football. He had a bad fall which led to his
admission to hospital for a week. He was received after the test showed that there was no
permanent injury. Sometimes he experiences weaknesses in his right arm but has no problem
coordinating his limbs. He has no numbness or tingling. He also does not have issues swallowing
or speaking. After a long day of exhaustion, he may experience problems speaking and has no
history of meningitis, stroke, spinal cord injury, a congenital defect. However, his mother passed
away due to meningitis. Mark is also an alcoholic.
Physical Assessment
Cranial Nerves
a) CN I-Olfactory
The patient complained of loss of smell
b) CN II-optic

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1 Assessment Name Institution date 2 Documentation of Assessment of the Neurological System Examiner: Susan Blake Date: Patient: Noses Mark Date of Birth: 11. 01.1990 Reason for Visit: Headaches Health History The patient has been having severe headaches for about two months. There have been persistent painkillers, which only relieve him of the pain for a short moment. The patient explains that he was once involved in an accident as he played football. He had a bad fall which led to his admission to hospital for a week. He was received after the test showed that there was no permanent injury. Sometimes he experiences weaknesses in his right arm but has no problem coordinating his limbs. He has no numbness or tingling. He also does not have issues swallowing or speaking. After a long day of exhaustion, he may experience problems speaking and has no history of meningitis, stroke, spinal cord injury, a congenital defect. However, his mother passed away due to meningitis. Mark is also an alcoholic. Physical Assessment Cranial Nerves a) CN I-Olfactory The patient complained of loss of smell b) CN II-optic 3 No issue was found with his optic c) CN III, IV, VI-oculomotor, trochlear and abducens Oculomotor tested the movement of the eye, especially after exposure to lighting. The eye responded reasonably well. Abducens also tested the movement of the eye by asking the patient to follow the finger. Trochlear tested for squirts which were negative. d) CN V-Trigeminal Good muscl ...
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