Assessment of the Nervous System_final (1) (1)

8/6/2019 Assessment of the Nervous System_final (1) (1)

1/76

A S S E S S M E N T O F T H EN E R V O U S S YS T E M


2/76

OBJECTIVES After completion of this session the students should be able

: To learn a basic Nervous System Examination

To differentiate between normal and abnormal responsesrelated to the neurologic system

To apply findings to common clinical presentations

To document findings in a structured, systematic way


3/76

Outlines Introduction

Review of anatomy and physiology

Nursing assessment


4/76

Introduction The nervous system consists of the central

nervous system (CNS), the peripheral nervoussystem, and the autonomic nervous system.

Together these three components integrate allphysical, emotional, and intellectual activities.

The CNS includes the brain and spinal cord. These two structures collect and interpret

voluntary and involuntary sensory and motorsignals.


5/76

Introduction The peripheral nervous system consists of the

12 pairs of cranial nerves and peripheralnerves. Most peripheral nerves contain both

motor and sensory fibers.


6/76


7/76


8/76

Purposes of Neurologic

Assessment To collect baseline data to aid in establishing the

etiology, diagnosis and prognosis To evaluate the present state of psychological

functioning to evaluate changes in individuals emotional,

intellectual, motor, and perceptual responses To determine the guidelines of treatment plan To ascertain if some seemingly psychopathological

response, is in fact a disorder of the sensory organ(i.e., a deaf person appearing hostile)


9/76

Three important questions govern

the neurologic examination:1) Is the metal status intact?

2) Are right-sided and left-sided findingssymmetric?

3) If the findings are asymmetric or otherwiseabnormal, does the causative lesion lie in theCNS or the peripheral nervous system?


10/76

Components of a Neurologic

Assessment1.INTERVIEW

The patient/family interview will allow the nurse to:

gather data: both subjective and objective about the patient's

previous/present health state provide information to patient/family

clarify information

make appropriate referrals

develop a good working relationship with both the patient and

the family

initiate the development of a written plan of care which is

patient specific


11/76

Components of a Neurological

Assessment1.Mental Status

2.Cerebellar Functions

3.Cranial Nerve Testing4.Sensory

5.Motor Function

6.Reflexes


12/76

ToolsThe following tools will be used during

the neurological exam:Gloves

Reflex hammer (tomahawk

model)

Penlight

Tongue blade

Safety pin

Cotton swab

Ophthalmoscope

Eye chart

Tuning fork

Coffee


13/76

I. The Mental Status

Appearance and behavior Speech and Language Moods and Thought perception Cognitive Functions


14/76

General appearance, manner

and attitude A simple means of gathering a great deal of

information about the patient's neurological

system is to observe the patient walking,talking, seeing, and hearing. Watching thepatient enter the room is also important ingiving the examinerinformation.


15/76

As the patient enters the room, check the following:

Posture and motor behavior, purposeful movements

and gestures

Dress, grooming, and personal hygiene.

Facial expression.

Speech manner, mood, and relation to persons and

things around him

General appearance, manner

and attitude


16/76

L e v e l o f c o n s c i o u s n e s sThe single most valuable indicator of neurological function is

the individual's level of consciousness. You can legally describe the patient's condition in the nursing

notes by saying, "appears to be" alert or lethargic or so forth. Alert. The patient is awake and verbally and motorally

responsive. Confused. The patient may de disoriented to time, place and

person and has poor judgment and may not think clearly.

Lethargic. The patient is sleepy or drowsy and will awakenand respond appropriately to command.


17/76

Obtundation. The patient is difficult to arouse and needs

constant stimulation to follow commands. He may respondwith a few words but will drift back to sleep when the

stimulus is removed Stupor. The patient becomes unconscious spontaneously

and is very hard to awaken. Semi coma. The patient is not awake but will respond

purposefully to deep pain. Coma. The patient is completely unresponsive.

***Consciousness is the most sensitive indicator of

neurological change**

L e v e l o f c o n s c i o u s n e s s


18/76

Assessment of UnconsciousClient

GLASGOW COMA SCALE useful for

monitoring changes during the firstfew

days after acute injury or inunstable

comatose clients.

SCALE is divided into three (3) subscales

Eye Opening

Verbal Response

Motor Response


19/76

GLASGOW COMA SCALE

Best Eye ResponseSpontaneously4

On command3

To Pain2

No response1

Best Verbal ResponseAlert & Oriented5Confused4

Inappropriate3

Incomprehensive2

No Response1

Best Motor Response

Follows Direction6

Localizes Pain5Withdraws from Pain4

Abnormal Flexions3

Abnormal Extensions2

NO Response1


20/76

EYE OPENING (Max score 4) 4 Spontaneous eye opening. 3 Eye opening in response to speech - that is, any

speech or shout. 2 Eye opening in response to pain. 1 No eye opening. TOTAL SCORE ...... / 15 RECORD YOUR FINDINGS

You may record you findings on a specific CNS chart.

Otherwise record in the following fashion:

The Glasgow coma scale (GCS)


21/76

ASSESS GRADES OF BEST VERBAL RESPONSE (Maxscore 5)

5 Oriented - patient knows who & where they are, and why,and the year, season & month.

4 Confused conversation - patient responds inconversational manner, with some disorientation andconfusion.

3 Inappropriate speech - random or exclamatory speech, noconversational exchange.

2 Incomprehensible speech - no words uttered, only

moaning. 1 No verbal response.



22/76


ASSESS GRADES OF BEST MOTOR RESPONSE(Max score 6)

6 Carrying out request ('obeying command')

5 Localizing response to pain. 4 Withdrawal to pain - pulls limb away from painful

stimulus. 3 Flexor response to pain - pressure on nail bed

causes abnormal flexion of limbs 2 Extensor posturing to pain - stimulus causes limbextension

1 No response to pain.


23/76

Speech and Language

Note the quality, rate, loudness, clarity, and

fluency of speech. If indicated, test for

aphasia


24/76

TESTING FOR APHASIATEST FINDINGS

Word Comprehension Ask client to follow a one-stagecommand, such as Point to yournose. Try a two-stage command:

Point to your mount thenyour knee

Repetition Ask client to repeat a phrase of onesyllabus words ( the most difficultrepetition task)

NOTE: No ifs, ands or buts.Naming Ask client to name he parts of the

watch.

Reading comprehension

Writing

Asks client to read a paragraphaloud.

Ask client to write a sentence


25/76

Thought and Perception

Assess coherency, logic and relevance-Where were you born?; What kind of work doyou do?

Ask about the patients spirits, if indicated,assess for suicide tendencies and depression.

Assess perception and reaction- How do youyourself now that you are in the hospital?


26/76

Affect/Mood

During the physical part of the examination, note thepatient's mood and emotional expressions which you canobserve by his verbal and nonverbal behavior.

Notice if he has mood swings or behaves as though he isanxious or depressed.

Notice whether or not the patient's feelings areappropriate for the situation.

Disturbances in mood, affect, and feelings may be

indicated by a patient who exhibits unresponsiveness,hopelessness, agitation, euphoria, irritability, or widemood swings.


27/76

Cognitive Functions

Assess reality orientation: time, place and

person- orderly progression of thoughts

based in reality.


28/76

Cognitive Functions

Attention

Digit span-ability to repeat a series of

numbers forward and then backwardSpelling backward-five letter word such as

W-O-R-L-D


29/76

Calculations in basic

mathematics

Serial 7s ability to subtract 7 repeatedly,

starting with 100

Ask the patient to do some simple arithmetic

problems without using paper and pencil. Forexample, ask him to add 7s or to subtract 3s

backwards.

It should take the patient of average intelligenceabout one minute to complete the calculations

with few errors.


30/76

Memory (recent and remote(

Recent Memory(e.g. events of the day

Remote memory e.g., birthdays,

anniversaries, social security number,schools attended

New learning ability (recall) ability to

listen and respond with understanding orknowledge; ask the client to repeat a

phrase, or three of four words


31/76

Higher Cognitive Functions

Knowledge (normal intellect(

Information and vocabulary

Calculating abilities

Abstract thinking

Constructional abilities

Ask the patient to name five large cities, major rivers, etc.Another way to test this area is to ask the patient to tell you the

meaning of proverb, or metaphor. For example, explain:

Too many cooks spoil the soup. A penny saved is a penny earned. A stitch in time saves nine


32/76

II. The Cerebellar Functions These include tests for balance and coordination.

The cerebellum controls the skeletal muscles and

coordinates voluntary muscular movement.

Ask the patient to walk back and forth across theroom.

Observe for equality of arm swing , balance andrapidity and ease of turning.


33/76

Cerebellar Functions1.Finger to finger test: have the patient touch

their index finger to your index finger (repeat

several times).

2.Finger to nose test: perform with eyes open

and then eyes closed.

3.Tandem walking: heel to toe on a straight line

4.Romberg test


34/76

The Romberg Test

Instruct the patient to stand with his feettogether and his arms at his side.

Have the patient do this with his eyes openand then with his eyes closed. Stand closeto the patient to keep him upright if he startsto sway.(

Expect the patient to sway slightly but not fall.This is a test of balance.

If the patient begins to sway, have them opentheir eyes. If swaying continues, the test ispositive or suggestive of problem ofcerebellum


35/76

Positioning

Usually tested only on the great toes butit can be tested on the fingers too.

Ask the patient to shut his eyes. Graspthe side of the toe between index fingerand thumb. This prevents movementfrom being felt as pressure up or down.

Move the digit up or down and ask thepatient to tell you the direction ofmovement


36/76

Rapid alternating movements

test

Seat the patient. Instruct him to pat his knees

with his hands, palms down then palms up.

Have him alternate palms down and palms up

rapidly.

Watch the patient to notice if his movements

are stiff, slow, nonrhythmic, or jerky.

The movements should be smooth andrhythmic as he does the task faster.


37/76

III. The Cranial NervesEvaluating the cranial nerves is an important

part of the neurological examination.

Taste and smell are usually not checkedunless a problem is suspected in thoseareas.


38/76

Cranial Nerve I, TheOlfactory Nerve The olfactory nerve is not commonly tested during a

screening physical exam but can be performed if damagesecondary to trauma or intracranial mass is suspected.

Each nostril should first be evaluated for potency bycompressing one nostril and having the patient breaththrough the opposite.

Each nostril should then be tested separately with avolatile, non-irritating substance such as cloves, coffee orvanilla. The patient should close his eyes, occlude onenostril and identify the substance placed under the opennostril.


39/76

Pupils:To examine cranial nerves II , III and mid-brain connectionsPUPILLARY ASSESSMENT

When assessing pupils (eyes) it is important to assess the

following:

size shape

reactivity to light

comparison of one pupil to the other


40/76

Pupils: Reaction to LightTo examine cranial nerves II , III and mid-brain connections Have the patient look at a distant object Look at size, shape and symmetry ofpupils. Shine a light into each eye and observe constriction of pupil. Flash a light on one pupil and watch it contract briskly.

Flash the light again and watch the opposite pupil constrict(consensual reflex

Repeat this procedure on the opposite eye. Normal: Pupil size is 3-5 mm in diameter.

They react briskly to light. Both pupils constrict consensually.


41/76

Pupils: SizeTo examine cranial nerves II , III and mid-brain connections

Pupils can be described according to their size (in mm) or by description:

Pinpoint: Seen with opiate overdose and pontine hemorrhage.

Small: Normal if the person is in a bright room.

May be seen with Horner's syndrome, pontine hemorrhage, ophthalmic drops,

metabolic coma etc.Midposition: Seen normally.

If pupils are midposition and nonreactive the cause is midbrain damage.

Large: Seen normally when the room is dark.

May be seen with some drugs and some orbital injuries.

Dilated: Always an abnormal finding.

Bilateral, fixed and dilated pupils are seen in the terminal stage of severe anoxia-

ischemia or at death.

Anti-cholinergic drugs can dilate pupils


42/76

Vision: Visual AcuityTo examine cranial nerve II and ocularfunction Position yourself in front of the patient.

Test the patient's visual acuity, each eye separatelycoveringone at a time.

Snellen's chart is used by Ophthalmologists. Visual acuity isrecorded as a fraction. The numerator indicates the distance (infeet) from the chart which the subject can read the line.

The denominator indicates the distance at which a normal eye canread the line. Normal vision is 20/20.

A pocket screeneris used at the bedside. Hold the pocketscreenerat a distance of 12-14 inches. At this distance theletters are equivalent to those on Snellen's chart.


43/76

Vision field By confrontation

Position yourself in front of the patient. The nose normally cuts off the medial field of vision. Hence, compare the patient's right eye to your left eye and vice

versa.

Instruct the patient to look straight at you and not to move their eyes. Compare your field of vision with the subject's. Bring your finger from the right field of vision until it is recognized. Test one quadrant at a time. Wiggle your fingers to see whether the patient can recognize the

movement. Some like to have the patient count fingers, i.e., 1, 2 or 5. Test all four quadrants in a similar fashion. When abnormality is detected , would require automated methods of

testing in the lab


44/76

Extraocular MusclesTo examine cranial nerves III, IVand VI Inspect the eyes. Look for symmetry ofeyelids. Note the alignment of the eyes at rest. Ductions: Movement of one eye at a time

Versions: Both eye movement Have the patient follow an object into each of the nine

cardinal fields ofgaze. Note that both eyes move together into each field. Eye movements should be smooth and without jerking.

Eyelids should be gently lifted up by the examiner's fingerswhen testing downward gaze. Jerky, oscillatory eye movements (nystagmus) may be

abnormal, especially if sustained or asymmetrical.


45/76

CN V: TrigeminalCorneal reflex: patient looks up and away.

Touch cotton wool to other side. Look for blink in both eyes, ask if can sense it.

Repeat other side [tests V sensory, VII motor].Facial sensation: sterile sharp item on forehead,

cheek, jaw. Repeat with dull object. Ask to report sharp or dull. If abnormal, then temperature [heated/ water-cooled

tuning fork], light touch [cotton].Motor: pt opens mouth, clenches teeth (pterygoids).

Palpate temporal, masseter muscles as they clench.


46/76

Motor Function: FacialMusclesTo test cranial nerve VII Inspect the face. Look forasymmetry at rest,

during conversation and when testing variousmuscles.

Ask the patient to wrinkle his forehead or raisehis eyebrows, enabling you to test the upper face(frontalis)

Next, have the patient tightly close his eyes. Testthe strength of the orbicularis oculi by gentlytrying to pry open the patient's upper eyelid.

Instruct him to puff out both cheeks. Checktension by tapping his cheeks with your fingers.

Have the patient smile broadly and show histeeth, testing the lower face.

Normal: No facial asymmetry.

Wrinkling of the forehead and smiling are equaland symmetrical


47/76


48/76

CNVIII: Hearing

With eyes closed, the patient should be instructed toacknowledge hearing the gentle rubbing of the examiner'sfingers approximately 3-4 inches away from his right andleft ear.

A watch, which the examiner can hear at a specificdistance from his ear, is placed next to the patient's ear.Ask him to note when the watch sound disappears. Notethat the examiner has to have normal hearing to do thisexam (in at least one ear(

Normal: In a quiet room, the patient should be able to hear the

physician's fingers rubbed lightly together 3-4 inches fromhis ear.


49/76

CN IX and X

These tests will evaluatecertain structures in themouth.

The nurse ask the patient to

say "aah" and can detectabnormal positioning ofcertain structures such as thepalatel-uvula.

The examiner will also assess

the sensation capabilities ofthe pharynx, by stimulatingthe area with a wooden tonguedepressor, causing a gagreflex.


50/76

CNXI

Inspect Trapezius andSternocleidomastoid muscles

Note muscle size (bulk). Look forasymmetry, atrophy and

fasciculation. Determine muscle powerby gently trying

to overpower contraction of each group ofmuscles.

Have patient shrug shoulder againstresistance and evaluate strength ofTrapezius muscle.

Have patient turn head to one side againstresistance and evaluate strength andobserve contracting sternomastoid muscle


51/76

CNXII

This nerve tests the bulk

and power of the tongue.

The examiner looks fortongue protrusion and/or

abnormal movements


52/76


53/76

IV. Sensory Function Testing for sensory function is the most difficult and

the least reliable part of the examination. Perform twotests.

(1) Test for pain. Perform this test using pin pricks in the

arms and legs. Ask the patient to say "sharp" or "dull"after each stimulus and to reply immediately.

This is a test of the patient's response to superficial pain.Usually, a sterile needle with a sharp point and dull hubon the other end is the instrument used. In a

nonpredictable pattern, touch the patient's skin with oneor the other end of the needle.


54/76

Test for touch

Touch the skin with a cotton ball using light

strokes. Do not press down on the skin or

touch areas of the skin that have hair. Instructthe patient to point to the area you have

touched or tell you when he feels the

sensation of being touched. (Obviously, he will

not be watching you touch his skin.(


55/76

Te s t f o r Te m p e r a tu r e Testing for temperature sensation is often

overlooked but it can be important. Tubes of hot and cold water may be used but

an easier and more practical approach is oftento touch the patient with a tuning fork as themetal feels cold.

First touch the patient where sensation isthought to be normal and say, "Does that feel

cold?" Then, when testing the limb, check thatthe patient is feeling the fork as cold and notjust as pressure


56/76

V. The Motor SystemWhen assessing motor function, from a neurological

perspective, the assessment should focus on arm and

leg movement. You should consider the following:

1.muscle size2.muscle tone

3.muscle strength

4.involuntary movements

5.posture, gait


57/76

Motor SystemInspectionStart by looking at the patient. Do

muscles look wasted? Is thereasymmetry? If the nurse strike the affected muscle

with a jerk hammer, it may induce

fasciculation.


58/76

Motor Functions AssessmentTerm Common Meaning

Strong Normal Strength

Weak Not as strong as expected, moves against resistance but weak.

Unable to lift Cant bring limb off the bed, cant move against gravity

Withdraws Pulls back from pain source

Reflex Involves contraction of muscle in response to pain

Decorticate To painful stimuli: flexes arms, wrists with adduction of the upperextremities & extension, internal rotation & plantar flexion of

Lower extremities

Decerebrate To painful Stimuli : extends, abducts and hyperpronates arms &stiffly extends legs & plantar flexes feet.

Flaccid No response to pain, no muscle tone

Ataxia Incoordination of voluntary muscle groups.


59/76

Note : Findings are recorded as afraction with 5 ( highest possible

Score) as the denomination

Ex: Normal ----------------- 5/5

Range of Motion

1.Flexion

2.Extension

3.Abduction4.Adduction

5.Rotation ( Internal & External)

Grading Reflexes

Hyperacative4+

Brisker than average3+

Average, NORMAL2+

Diminished, low N1+

No Response0+

Motor Functions Assessment


60/76

Note : Findings are recorded as a

fraction with 5 ( highest possibleScore) as

the denomination

Ex: Normal ----------------- 5/5

Motor Functions Assessment

Grade Strength

5Full ROM against gravity and resistance; normal

muscle strength

4Full ROM against gravity and a moderate amount of

resistance; slight weakness3Full ROM against gravity only, moderate muscle

weakness

2Full range of motion when gravity is eliminated, severe

weakness1A weak muscle contraction is palpated, but no

movement is noted, very severe weakness

0Complete paralysis


61/76

Motor SystemIn a conscious patient, the single best test to quickly

identify motor weakness is the drift test. Have thepatient hold their arms outward at 90 degrees fromthe body. With palms up, have the patient close theireyes and hold the arms for a couple of minutes.Drifting will occur if one side is weak.
http://i.pbase.com/v3/35/25535/2/47574778.IMG_1076.jpg


62/76

Abnormal posturing

Decorticate posturingLegs and feet extendedwith planter

flexion and arms rotatedand

flexed on chest

Decerebrate posturing

Arms stiffly extended and hands turned

outward and flexed,leg also extended

with planter flexion

Decorticate posture may progress todecerebrate posture, or the two may alternate.

The posturing may occur on one or both sides

of the body.
http://i.pbase.com/v3/35/25535/2/47574778.IMG_1076.jpg


63/76

VI. The Reflexes

A reflex is defined as an immediate and involuntaryresponse to a stimulus.

Superficial reflexes. Stroke the skin with a hard object such as an applicator

stick. What is felt is a superficial reflex 5 Ps Pain Pallor Pulses Paresthesia Paralysis


64/76

Biceps--deep tendon reflex

1- Have the patient's elbow at about a 90angle of flexion with the arm slightly bentdown as shown in figure 2-6.

2- Grasp the elbow with your left hand so thefingers are behind the elbow and yourabductee thumb presses the bicepsbrachial tendon.

3- Strike your thumb a series of blows withthe rubber hammer, varying your thumb

pressure with each blow until the mostsatisfactory response is obtained.

4- Normal reflex is elbow flexion (bending(


65/76

Triceps--deep tendon reflex

Grasp the patient's wrist withyour left hand and pull his arm

across his chest so the elbow isflexed about 90 and the

forearm is partially bent down.

Tap the triceps brachial tendondirectly above the olecranon

process. The normal response

is elbow extension.

Triceps reflex

Triceps jerk with arms folded

Triceps jerk with one arm

flexed


66/76

Plantar (Babinski) reflex Lightly stimulate the outer margin of

the sole of the foot to get this reflex.Perform the reflex check in thismanner:

Grasp the ankle with your left hand. Use a blunt point and moderatepressure and stroke the sole of the footnear its lateral border.

Stroke from the heel toward the ball ofthe foot where the course should curve

across the ball of the foot to the medialside, following the bases of the toes.

A normal reflex is for the patient to haveplantar flexion of all his toes.


67/76

Patellar reflex

(kneejerk)

Test the reflex in this manner

1 -Have the patient sit on a table orhigh bed to allow his legs to swingfreely.

2 -Tap the patellar tendon directly witha rubber hammer.

3 -Normally, the knee extends.

4 -Conduct the reflex check as shownin this figure if the patient must belying down. Put your hand under the

popliteal fossa and lift the patient'sknee from the table or bed. Tap thepatellar tendon directly.


68/76

Achilles reflex (ankle jerk) Tap the Achilles tendon and the foot

should extend from the contraction of thegastrocnemius and soleus musclesresponding to that tap. Perform the reflextest in this manner:

Have the patient sit on a table or bed sothat his legs dangle. With your left hand, grasp the patient's

foot and pull it in dorsiflexion (upward).Find the degree of stretching upward ofthe Achilles tendon that produces the

optimal response. Tap the tendon directly. Normal response is contraction of the

gastrocnemius and plantar flexion of thefoot.


69/76

Deep tendon reflexes should be

graded on a scale of 0-4

as follows:

= 0 absent despite reinforcement

= 1 present only with reinforcement= 2 normal

= 3 increased but normal

= 4 markedly hyperactive, with clonus


70/76

Others: Vital Signs

Changes in vital signs are not consistent earlywarning signals.

Both respiratory and cardiac centres are located inthe brainstem.

Therefore, compression of the brainstem will causechanges in vital signs.

This is usually a late sign and impendingherniation/death will occur if the problem is notresolved.

Do not forget to compare findings to previousassessment

Others: CONVULSION SCORING


71/76

CHART(Rhea et al.(Factors 0 1 2

Occurrence None in 24 hours Occur only instimulation

Occurspontaneously

Duration fleeting Last between 10-60sec.

Longer than1minute

Severity Mild twitching Moderate clonus Severe shaking

Frequency More than 60minutes apart

60-10 minutesapart

Less than 10minutes apart

Ventilation adquate impaired Impaired to thepoint of cyanosis

*Score is done every 4 hours

Interpretation:Score above 7 increase the dose of anticonvulsant

Score of 5-7 may be transitional. If it tends to increase from 5-7 during a 24-hour period,

convulsion potential is still high, but if reversed, patient is stable and improving

Score 2-4 are important to observe the trends, but there is less urgency. A stable score in

this range by the late 2nd or 3rd week, recovery is expected


72/76

In Summary


73/76

ASSESSMENT OF THENEUROLOGICAL SYSTEM:Establishing Nursing Data Base

a. Demographic Profile

b. Chief complains

c. Present Illness

c.1: Assess the circumstances of injury and admission

c.2: Assess Chief Complaint

A any associated Sx with cc

P - what provokes ( make worst) or (Makes better)

Q - Quality of Pain

R - Region and RadiationS - Severity of pain 1-10

T - Timing ( when did it start & stop, intermittent

or constant duration

d. Past and Family History


74/76

2.Review of System

3.Comprehensive Physical Assessment including Vital signs

4.Comprehensive Neuro Assessment

3mportant Questions govern the Neurological Examination1.Is mental status intact?

2.Are Right sided & left sided findings symmetric?

3.If findings are asymmetric or otherwise abnormal, does the causative

lesion lie in the CNS or the Peripheral Nervous System?

ASSESSMENT OF THENEUROLOGICAL SYSTEM:


75/76

Components of a Neurological

Assessment

1.Mental Status

2.Cerebellar Functions

3.Cranial Nerve Testing

4.Sensory

5.Motor Function

6.Reflexes


76/76

Documents

Assessment of the Nervous System_final (1) (1)