Neuro Asessment
Subjective
30 year old Caucasian female c/o HA. (P) Pt first noticed HA on her way home from school. HA occurs in afternoons, usually around 4 pm. Resting alleviates pain. Exercise, not enough sleep aggravates pain. Pt takes Ibuprofen (400 mg) and Sudafed. Pt does not recall Sudafed dose. (Q) Pain aching, throbbing, sometimes stabbing. (R) HA pain on right side of head. Sometimes radiates along right side of neck up to forehead. Pt denies other symptoms associated with HA pain. (S) Pt rates pain 7 out of 0 to 10 on pain scale. (T) Pain onset 1 yr ago, September 2012. Pain lasts approx. 6 hrs. Usually occurs daily, approx. 4 – 6 HA per week. Last episode yesterday, October 8, 2013. (U) Pt unable to study, work. HA affects concentration, focus. Pt “afraid I won’t get all my studying done for school.” Pt worried there could be something else associated with HA. Pt denies head injuries, losing consciousness, dizziness/vertigo, seizures/convulsions, and tremors in hands or face. Pt denies body weakness, problems with coordination, numbness/tingling, difficulty swallowing, and difficulty speaking. Pt denies decrease in memory or change in mental function, sudden vision change, loss of smell, and environment/occupational hazards. Pt also denies past history of stroke, spinal cord injury, meningitis, congenital defect, and alcoholism.
Objective
Balance:
Gait smooth, relaxed, even with accurate and symmetric foot placement. Upright trunk posture, slight swaying. Arm swing smooth, symmetric, coordinated with opposing arm. Turns smoothly and balances easily. Pt able to tandem walk (walk in straight line). Consistent contact between heel and toe, slight swaying. Pt maintained balance walking on toes only, heels only. Romberg test negative. Pt maintained posture and balance. Pt performed shallow knee bend bilaterally.
Coordination:
Rapid alternating movements (RAM) coordinated, smooth, equally bilaterally. RAM performed quickly, pt maintained rhythm with
30 year old Caucasian female c/o HA. (P) Pt first noticed HA on her way home from school. HA occurs in afternoons, usually around 4 pm. Resting alleviates pain. Exercise, not enough sleep aggravates pain. Pt takes Ibuprofen (400 mg) and Sudafed. Pt does not recall Sudafed dose. (Q) Pain aching, throbbing, sometimes stabbing. (R) HA pain on right side of head. Sometimes radiates along right side of neck up to forehead. Pt denies other symptoms associated with HA pain. (S) Pt rates pain 7 out of 0 to 10 on pain scale. (T) Pain onset 1 yr ago, September 2012. Pain lasts approx. 6 hrs. Usually occurs daily, approx. 4 – 6 HA per week. Last episode yesterday, October 8, 2013. (U) Pt unable to study, work. HA affects concentration, focus. Pt “afraid I won’t get all my studying done for school.” Pt worried there could be something else associated with HA. Pt denies head injuries, losing consciousness, dizziness/vertigo, seizures/convulsions, and tremors in hands or face. Pt denies body weakness, problems with coordination, numbness/tingling, difficulty swallowing, and difficulty speaking. Pt denies decrease in memory or change in mental function, sudden vision change, loss of smell, and environment/occupational hazards. Pt also denies past history of stroke, spinal cord injury, meningitis, congenital defect, and alcoholism.
Objective
Balance:
Gait smooth, relaxed, even with accurate and symmetric foot placement. Upright trunk posture, slight swaying. Arm swing smooth, symmetric, coordinated with opposing arm. Turns smoothly and balances easily. Pt able to tandem walk (walk in straight line). Consistent contact between heel and toe, slight swaying. Pt maintained balance walking on toes only, heels only. Romberg test negative. Pt maintained posture and balance. Pt performed shallow knee bend bilaterally.
Coordination:
Rapid alternating movements (RAM) coordinated, smooth, equally bilaterally. RAM performed quickly, pt maintained rhythm with