Case Taking Proforma - Central Nervous System 51kh

1 Name/Age/Sex/Occupation/Address/handedness Presenting Complaints: • • •

H/o weakness / inability to use limbs H/o mouth angle defect H/o speech defect

History of Presenting complaints: Weakness/ inability: o Sequence of events in patients own words which includes Duration Onset – sudden / insidious Time of occurence – sleep / work Progression Tone – flaccid / rigid Weakness of • Upper limb o Proximal: H/o combing hair, lifting hand o Distal: H/o mixing food, buttoning shirt, writing • Lower limb o Proximal: H/o standing, climbing stairs o Distal: H/o slippers slipping • Trunk o H/o turning from side to side • Neck o H/o difficulty to lift head from bed H/o fasciculation / atrophy H/o sensory loss o Temperature sense: warm / cold water o Touch sense: feeling shirts, dresses o Pain sense: pinching o Others: tingling, numbness, root pain H/o loss of consciousness o Duration o Complete / partial o Aura +/o Associated with (to rule out odd’s palsy) o Bowel / Bladder disturbance o Recovery period o Frequency of occurence

2 History suggestive of etiology • H/o thrombus Vomiting, diarrhoea (calf tenderness) • H/o embolism Chest pain, palpitation, fever with meningitis, TB • H/o haemorrhage Trauma, headache, projectile vomitting, blurring of vision, convulsions, bleeding diathesis Level of lesion o H/o cortex Aphasia Bladder involvement Convulsion o H/o corona radiata o H/o Internal capsule o H/o brain stem Cranial nerves o I : H/o loss of sense of smell / altered o II : H/o disturbance of vision o III, IV, VI : H/o diplopia, difficulty in eye movements o V : H/o sensory loss over face, chewing disturbances o VII : H/o loss of taste, salivation, angle deviation, drooling of saliva from mouth o VIII : H/o hearing loss, vertigo, tinnitus o IX, X : H/o nasal regurgitation, nasal twang, dysphagia, hoarseness of voice o XII : H/o dysarthria ANS history: o H/o bowel: Constipation / loss of control o H/o bladder: Difficulty in feeling the filling / Difficulty in initiating / Difficulty in controlling / Difficulty in complete evacuation / Dribbling o Impotence: o Sweating: Past History: o o o o o o

H/o previous episodes H/o TIA, RIND (Reversible Ischemic Neurological Deficit) H/o DM, TB, HT, STD H/o recurrent headache, vomiting, diarrhoea, fever H/o cardiac disease, epilepsy, trauma H/o CSOM, ARV, dogbite

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H/o drugs, surgery, Os, poisoning

Family History: o o o

Consanguinity Siblings Any similar episodes

Personal History: o o o o

Smoking Alcohol Diet --> lathyrism, SACD STD history

Treatment History: Summary: Age/sex/name ? Handedness ? Personal H/o ? Family H/o ? PC ? other relevant positive findings Probable system involved ? CNS History Diagnosis: Acute CVA, which is probably due to ...................... which is.........................(progression) in nature, with associated cranial nerve involvement and ...........(no) sensory loss. The probable site of lesion is ........................... Examination of CNS case: General Examination: o o o o o o o o o o o o o

comfortable cooperative conscious oriented built nourishment febrile / afebrile pallor / not anemic Icteric / not Clubbing Cyanosis Pedal oedema Significant lymphadenopathy

4 Neurocutaneous markers: o Adenoma sebaceum o Ash leaf patches o Shagreen patches o Cafe au lait spots o Multiple neurofibromas o Tuft of hair in the back – spina bifida o Capillary haemangioma – Sturge weber syndrome (port wine stain) o Conjunctival haemangioma – Von Hippel Lindau syndrome o (with cerebellar haemangioma) o Pes cavum – Friedreich’s ataxia Markers of HIV Markers of TB Markers of FF syphilis o peripheral nerve thickening o spine angulation Vital signs: o o o o o

Pulse: rate, rhythm, volume, character, PV, RF, vessel wall BP RR Temperature JVP

Local Examination of CVS: A. Higher Function: a. Consciousness b. Orientation – time, place, person c. Memory – short, place, person d. Intelligence e. Speech f. Handedness g. Emotion B. Cranial nerves: I. Olfactory nerve: a. Clove +/- (Rt & Lt) b. Oil of peppermint +/c. Asafoetida +/II. Optic nerve: a. Visual acuity

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b. c. d.

i. Gross vision Distant vision Near vision Field of vision Colour vision Fundoscopy

III, IV, VI Occulomotor , Trochlear, abducent Extra ocular movements Pupil o Size o Reflexes Direct Consensual Accommodation Nystagmus Ptosis V Trigeminal Sensory – sensation over face and buccal mucosa Motor – Clenching of teeth ( masseter, temporalis, pterygoids) Reflex o Corneal o Conjunctival o Jaw jerk VII Facial nerve Motor o Wrinkling of forehead o Closing of eyelids o Showing teeth o Blowing of cheeks, whistling o Nasolabial folds o platysma o Hyperacusis (Stapedius) Sensory o Taste of Ant. 2/3 of tongue (Sugar, salt, vinegar) o Sensation over tongue Reflex

6 o Corneal o Conjunctival Secretomotor o Salivation o Lacrimation(Shirmer’s tear) VIII Vestibulocochlear nerve Cochlear o Rinne’s test o Weber test Vestibular o Caloric test IX X Glossopharyngeal, Vagus Taste (posterior 2/3 of tongue) IX Gag reflex Palatal reflex XI Spinal accessory nerve Shrugging of shoulders Turning head against resistance XII Hypoglossal nerve Tongue protrusion Fibrillation Wasting Power C. Motor System: Bulk o Inspection o Palpation UL – 10 cm from acromion – 10 cm below olecranon process LL – 18 cm from upper end of patella - 10 cm lower end of patella Tone o UL – N / clasp knife spasticity in flexors o LL – N / clasp knife spasticity in extensors Power o UL Shoulder • Flexion – extension

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• Abduction – adduction • Rotation Elbow • Flexion – extension Wrist • Flexion – extension • pronation – Supination • Adduction – Abduction Fingers • Flexion – extension • Abduction – Adduction Thumb • Flexion – extension • Abduction – Adduction • Opposition o Lower Limb Hip Jt • Flexion – extension • Abduction – adduction • Rotation Knee Jt. • Flexion Extension Ankle Jt • Dorsal – plantar flexion • Inversion – Eversion Toes • Flexion – extension • Adduction – Abduction Coordination: o Upper limb Finger nose test Finger – finger nose test Disdiadochokinesia o Lower limb Knee – heel test Drawing circle Gait o In hemiplegia – Adducted shoulder, Flexed elbow, Flexed and semipronated wrist, Flexion at MP jts, extension at IP jts Involuntary movements Reflexes

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Superficial reflexes Corneal (CN 5, 7) Conjunctival (CN 5,7) Pharyngeal (CN 9, 10) Abdominal (T8 – T12) Cremasteric (L1, L2) Plantar ( L5, S1) Deep reflexes Jaw jerk (CN 5) Biceps (C5, C6) Triceps (C6, C7, C8) Supinator (C5, C6) Knee jerk (L3, L4) clonus Ankle jerk (S1, S2) clonus

D. Sensory System: a. Superficial Touch Pain Temperature b. Deep • Pressure • Deep pain • Vibration sense • Position sense c. Cortical sense • Tactile localisation • Two point discrimination • Stereopsis • Graphesthesia d. meningeal irritation: • Neck rigidity • Kernig’s sign • Brudzinski’s sign Diagnosis: ...............................(Lt/Rt) sided hemiplegia .............................(with / without Lt/Rt) UMN facial palsy with lesion at .............................. (Rt/Lt) Internal capsule in the ..................................(Rt/Lt MCA territory) probably due to .........................(thrombosis / embolism / haemorrgage)