Cranial Nerves
- Right homonymous hemianopsia (loss of vision on one side) (CN II).
- Jaw weakness on right (CN V).
- Weakness in right lower face (CN VII).
- Weak shoulder shrug and head movement on right (CN XI). - Stroke affecting motor and sensory cranial nerve pathways on the right side.
Motor Function
- Right-sided hemiplegia (arm and leg).
- Spasticity and limited ROM in right arm and leg.
= Damage to the corticospinal tract from the stroke.
Normal
- Symmetrical muscle bulk and tone.
- No involuntary movements.
- No atrophy, weakness, or tremors.
- Smooth, coordinated gait; able to tandem walk.
- Negative Romberg test.
- Smooth and intact rapid alternating movements.
Abnormal
- - Muscle atrophy or hypertrophy.
- Spasticity, rigidity, or flaccidity.
- Involuntary movements like tremors or fasciculations.
- Muscle atrophy or weakness.
- Tremors or spasticity.
- Unsteady gait, ataxia, or inability to tandem walk.
- Positive Romberg test (loss of balance).
- clumsy rapid alternating movements
Sensory Function
- Reduced pinprick and light touch sensation in right arm and leg.
- Impaired position sense on right side.
= Cortical sensory loss from CVA.
Normal
- Normal perception of touch, pain, vibration, and position.
- Intact pinprick, light touch, and vibration sensation.
- Stereognosis intact (can identify objects by touch).
- Abnormal
- Decreased sensation (e.g., hypoesthesia, hypoalgesia, analgesia).
Inability to perceive vibration or proprioception. - Inability to identify objects (astereognosis).
Headache
- No frequent or severe headaches. - Frequent, severe headaches.
- Associated with neurological symptoms (e.g., vision changes, confusion).
Head Injury
- No history of head injury.
- Consistent helmet use for sports. - History of head trauma with loss of consciousness.
- Inconsistent helmet use.
- Persistent symptoms like confusion or dizziness post-injury.
Dizziness/Vertigo
- No dizziness or vertigo. - Lightheadedness (possible syncope).
- Rotational spinning sensation (true vertigo).
- Associated with positional changes or neurological disorders
Seizures
- No history of seizures. - Recurrent seizures with altered consciousness.
- Auras (auditory, visual, motor).
- Postictal confusion, muscle weakness, or headache.
Tremors
Normal
- No tremors observed.
Abnormal
- Involuntary shaking, worse with anxiety or purposeful movement.
- Senile tremor (relieved by alcohol).
- Tremors affecting daily or social activities.
Weakness
- No weakness or impaired movement. - Generalized or localized weakness (e.g., difficulty getting up or opening jars).
- Proximal or distal muscle weakness (paresis or paralysis).
Incoordination
- No problems with balance or coordination. - Difficulty walking straight.
- Clumsy or unsteady movements.
- Dysmetria (inability to control movement range).
Numbness/Tingling
- No numbness or tingling sensation.
- Paraesthesia (“pins and needles”) localized or generalized. (pressure and damage to the peripheral nerves)
- Burning or tingling sensations with activity.
Difficulty Swallowing
- No problems swallowing. - Dysphagia (difficulty with solids or liquids).
- Excessive drooling or salivation.
Difficulty Speaking
- Clear and coherent speech. - Dysarthria (difficulty forming words).
- Aphasia (difficulty comprehending or expressing language).
Significant Past History
- No history of stroke, spinal cord injury, meningitis, or congenital defects. - History of neurological diseases (e.g., stroke, encephalitis).
Environmental Hazards
- No exposure to harmful substances or excessive alcohol use. - Exposure to insecticides, organic solvents, or lead.
- Regular alcohol or recreational drug use.
Risk for Falls (Older Adults)
- Stable balance and no dizziness upon positional changes. - Dizziness or fainting upon standing.
- Increased risk of falls due to poor balance or positional changes (e.g., micturition syncope).
Cognitive Function (Older Adults)
- No changes in memory or mental clarity. - Sudden or gradual memory loss.
- Confusion or disorientation.
Vision (Older Adults)
- Stable vision with no changes. - Sudden vision changes or blindness.
- Associated weakness or loss of consciousness (possible stroke).
Reflexes
- Hyperactive reflexes with clonus on the right side.
- Upgoing toes (positive Babinski sign) on right.
= Upper motor neuron lesion due to CVA.
Normal
- - Reflexes graded 2+ (normal).
- No Babinski sign (downgoing toes). = good
- Deep tendon reflexes (DTRs) graded 2+ bilaterally.
Abnormal
- Hyporeflexia (diminished reflexes due to lower motor neuron issues).
- Hyperreflexia (exaggerated reflexes due to upper motor neuron issues) (graded 4+) with clonus.
- Positive Babinski sign (upgoing toes).
- Absent abdominal or cremasteric reflexes.
Gait
- Smooth, rhythmic, and coordinated gait.
- Ataxia (unsteady or uncoordinated gait).
- Inability to perform tandem walking.
Romberg Test
- Able to maintain balance with eyes closed.
- Positive Romberg sign (loss of balance when eyes are closed).
- Indicates cerebellar ataxia, proprioceptive, or vestibular dysfunction.
Mental Status
- Slow, effortful speech.
- Limited verbal output, mostly one-word answers. - Aphasia due to cerebrovascular accident (CVA).
- Appearance, behavior, and speech appropriate.
- Alert and oriented to person, place, and time.
- Memory intact (recent and remote). - Confusion, disorientation.
- Memory loss (short-term or long-term).
- Inappropriate behavior or speech patterns.
