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
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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 H/o previous episodes

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

Family History:

o Consanguinity
o Siblings
o Any similar episodes

Personal History:

o Smoking
o Alcohol
o Diet --> lathyrism, SACD
o 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 comfortable
o cooperative
o conscious
o oriented
o built
o nourishment
o febrile / afebrile
o pallor / not anemic
o Icteric / not
o Clubbing
o Cyanosis
o Pedal oedema
o Significant lymphadenopathy
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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 Pulse: rate, rhythm, volume, character, PV, RF, vessel wall

o BP
o RR
o Temperature
o 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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i.
 Gross vision
 Distant vision
 Near vision
b. Field of vision
c. Colour vision
d. 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
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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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o Superficial reflexes
 Corneal (CN 5, 7)
 Conjunctival (CN 5,7)
 Pharyngeal (CN 9, 10)
 Abdominal (T8 – T12)
 Cremasteric (L1, L2)
 Plantar ( L5, S1)
o 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)