CENTRA NERVOUS SYSTEM

Name Age Sex Occupation Handedness Address

Presenting compliants

H/O inability to use the left upper and lower limb for the past 10 days associated with
deviation of angle of mouth and drooling of saliva
H/O slurring of speech for the past 10 days

H/O Presenting compliants

Before 10 days patient was apparently normal. On the day of event moring 5 am he went to toilet and
return back to bed, then he noticed that he was not able use his left upper and lower limb which is
associated with slurring of speech and deviation of angle of mouth.
(VII)
H/O of motor weakness of both proximal and distal muscle in the form of not able to use his left upper
limb and lower limb
Etiology
No H/O Head ache
No H/O Nausea
No H/O Vomiting
No H/O Epilepsy
No H/O Blurring of vision
No H/O Vomiting and Diarrhoea
No H/O Fever
No H/O Chest pain, palpitation, sweating
Motor
No H/O difficulty in turning side to side
No H/O difficulty in head rising(XI)
Sensory
No H/O sensory disturbances
Cranial Nerve
No H/O loss of sense of smell(I)
No H/O visual disturbances(II)
No H/O double vision, difficulty in eye movements(III,IV,VI)
No H/O sensory loss over the face, difficulty in chewing(V)
No H/O hard of hearing, vertigo and tinnitus(VIII)
No H/O nasal twang or nasal regurgitation(IX,X)
No H/O difficulty in tongue movement
Autonomic
No H/O bladder and bowel disturbances
No H/O muscle twitching
Past History

No H/O previous similar episodes

H/O of TIA, RIND
No of episodes
Duration of the episodes
Any visual disturbances
Recovery period
Aggravating/relieving factor
No H/O DM,HT, BA,IHD
No H/O STD
No H/O CSOM, recent vaccination for dog bite
No H/O recent surgery
No H/O trauma
No H/O OC pill intake, poisoning

Family History

Any other family members with similar compliants

Personal History
Smoking
Alcohol
Treatment History

Examination
General Examination
Consciousness
Comfortable
Afebrile
Built
Pallor
Jaundice
Clubbing
Cyanosis
Pedal Edema
Significant lymphadenopathy
Markers of Neurocutaneous markers
Adenoma sebaccum Tuberous sclerosis
Ash leaf patches Tuberous sclerosis
Shagreen patches Tuberous sclerosis
Tuft of hair on the back Spina bifida
Capillary hemangioma(Port wine stain) Sturge weber synd
Conjunctival hemangioma(With cerebral hemangioma) Von Hippel landau syn
 Markers of TB
Phlyctern
Scar/Sinus in the neck
Tenia versicolor
Lupus vulgaris
Erythema nodosum
Gynacomastia –INH
Markers of HIV
Oral hairy leukoplakia
Oral candidiasis
Molluscum contagiosum
Herpetic infection(Zooster)
Generalized lymphadenopathy
Vital Signs
Pulse (Rate, Rhythm, Volume, Character, Felt in all palpable peripheral vessels, any
Radio femoral delay)
BP(All limbs)
Temperature
JVP

Examination of CNS

Higher Function
Consciousness
Oriented to Time, Place, Person
Immediate, Recent, long term Memory are intact
Intelligence Normal
Slurring of speech
Handedness
Cranial Nerves Right Left
I Olfactory N N
Both nostrils are tested individually with a
non irritant substance asafetida and found to
be normal
II Optic
Visual acquity N N
Field of vision N N
Color vision N N

III Oculomotor
IV Trochlear
VI Abducent
Palpaberal Fissure N N
Extra occular movements N N
Pupil Size 4mm in dia 4mm in dia
Pupilary Reflex
Direct Reacting Reacting
 Consensual Reacting Reacting
Accommodation N N

V Trigeminal
Sensory over the face N N
Motor
Clenching of mouth N N
Reflex
Corneal N N
Conjunctival N N
Jaw jerk N N

VII Facial Nerve

Motor
Wrinkling of fore head
Tight closure of eyelid
Blowing of cheeks
Nasolabial Fold
Mandible Depression
Hyperacusis
Sensory
Tongue ant.2/3 Both sides of the tongue are tested
individually with salt, sugar solution and
found to be normal
Secoretomotor
Salivation N N
Lacrimation N N

VIII Vestibulo cochlear

Rinne Test N N
Weber Test N N

IX Glossopharyngeal
X Vagus
Gag reflex N
Palatal reflex N

XI Spinal accessory
Shrugging of shoulder N
Turning of head N

XII Hypoglossal
Tongue protrusion N
Movement against cheek N

Motor system
Bulk
No wasting of muscle
Upper limb circumference
10 cm from Acromion
10cm below olecranon process
Lowe limb circumference
18 cm form upper end of patella
10 cm below the lower end of patella

Power N N
Upper limb
Shoulder
Flexion 5/5 1/5
Extension 5/5 1/5
Abduction 5/5 1/5
Adduction 5/5 1/5
Rotation 5/5 1/5
Elbow
Flexion 5/5 1/5
Extension 5/5 1/5
Wrist
Flexion 5/5 1/5
Extension 5/5 1/5
Abduction 5/5 1/5
Adduction 5/5 1/5
Supination 5/5 1/5
Pronation
Fingers
Flexion 5/5 1/5
Extension 5/5 1/5
Abduction 5/5 1/5
Adduction 5/5 1/5
Lower Limb
Hip joint
Flexion 5/5 1/5
Extension 5/5 1/5
Abduction 5/5 1/5
Adduction 5/5 1/5
Rotation 5/5 1/5
Knee joint
Flexion 5/5 1/5
Extension 5/5 1/5
Ankle joint
Dorsiflexion 5/5 1/5
Plantar flexion 5/5 1/5
Toe
Flexion 5/5 1/5
Extension 5/5 1/5
Abduction 5/5 1/5
Adduction 5/5 1/5
Coordination
Upper limb
Finger nose test
Finger - finger nose test
Disdiadochokinesia
Lower limb
Heel – Knee test
Drawing circle
Gait
Circumduction Gait (Adducted shoulder, Flexed elbow, Flexed and semi pronated wrist, Flextion
at MP joints, Extension at IP joints)
Involuntary movements
No
Reflexes
Superficial Reflex
Abdominal (T8,L2)
Cremasteric (L1,L2)
Plantar (L5,S1) – Babinskis sign in the hemiplegic side
Deep reflex
Biceps
Triceps
Supinator
Knee jerk
Ankle jerk
Sensory system
Superficial
Touch
Pain
Temperature
Deep
Pressure
Deep pain
Vibration sense
Position sense
Cortical Sense
Tactile localization
2 point discrimination
Sterognosis
Graphasthesia
Meningeal irritation
Neck rigidity
Kernig’s sign
Brudzinskis sign
Diagnosis
A case of left sided hemiparesis with left sided UMN facial nerve palsy involving the lenticulate
striate branch of middle cerebral aretery with lesion at the internal capsule proably due to
thromboembolism.(Clinical feature + Anatomy + Pathology + Aetiology)