Good

1. Central Nervous System
KALYANI RAJU
FINAL YEAR MBBS

2. Patient Details
Name: Devaraj
Age: 65 ( more in old age , less than 45 young stroke)
Sex: Male ( males->> females)
Occupation: Farmer
Address: Thiruvallur
Handedness: Right handedness

3. Chief Complaints
• Weakness of left upper and lower limb for past 15 days
•Deviation of angle of mouth to right side for past 15 days

5. History of presenting illness
The patient was apparently normal before 15 days,
• On the day of onset, when he was about to go to bathroom at 6 AM, he suddenly felt weak
and could not move his left upper and lower limb. After getting admitted in the ward, his
condition is improving and stable.(thrombotic : wakes up with stroke, embolic or
hemoragic : during activity)
•Weakness for past 15 days
• Sudden in onset,
• Rapid progression of weakness to inability to use left upper and lower limbs .( deficit at
ondet maximum in embolic , others progressive)
• Not associated with loss of consciousness or slurred speech
•No h/o difficulty in lifting head from bed ( motor system ; head to foot)
• H/o difficulty in lifting left upper limb above head and picking things off shelves

6. • H/o difficulty in combing hair
• H/o difficulty in brushing the teeth and bringing food to mouth
• H/o difficulty in buttoning shirt, holding objects, mixing food and writing
•No H/o difficulty in breathing
•No h/o difficulty in turning side to side and getting up from lie down position
• H/o difficulty in standing and getting up from squatting position
•H/o difficulty in climbing up and down the stairs
•H/o buckling of knees
• H/o difficulty in holding slippers and tripping of toes
•Patient feels the limb being stiff. ( ask diurnal variations : to rule out myasthenia gravis)

7. •No h/o thinning of limbs
•No h/o fasciculations
•Able to feel clothes over body, hot and cold water sensation while bathing( sensory
system)
•No h/o pins and needles or benumbed sensation
•No h/o absence of smell/altered smell (cranial nerves 1 to 12)
•No h/o dimness of vision, inability to roll eyeball in various directions and difficulty in
colour vision
•No H/o loss of sensation over face and chewing disturbances
•H/o deviation of angle of mouth to right side, inability to show teeth and hold air in his
mouth

8. •No h/o inability to wrinkle forehead or screw eyelids tightly
•No h/o hard of hearing, vertigo or tinnitus
•No h/o nasal regurgitation, difficulty in swallowing or nasal intonation of voice
•No h/o inability to shrug shoulder
•No h/o inability to rotate tongue inside the oral cavity or roll food back through the
tongue
•No h/o increased tremulousness on reaching for objects (cerebellum)
•No h/o gait abnormality
•No h/o objects floating in front of his eyes
•No h/o slurring of speech

9. •No h/o giddiness on standing
•No h/o loss of sweating or loss of hair( autonomic system)
•No h/o constipation or loose stools
•Able to feel fullness of bladder, initiate micturition, feel the stream of urine passing
through urethra, able to empty the bladder completely
•No h/o increased frequency, urgency or bladder incontinence
•No h/o altered consciousness, memory loss or speech difficulties ( higher mental
functions)
•No h/o altered behaviour and the patient is anxious in general
•No h/o headache, blurring of vision, projectile vomiting, seizures or altered
sensorium( raised ict)

10. •No h/o fever and ear discharge (etiological history : csom and abscess ,
valvular heart diesases, dvt )
•No h/o chest pain, palpitations
• No h/o breathlessness
• No h/o vomiting, diarrhoea, calf tenderness
• No h/o trauma

11. Past History
•No h/o similar illness in the past like Stroke, TIA or RIND
•K/c/o Hypertension diagnosed 10 years back and is on regular medications
•Not a k/c/o Diabetes mellitus, Ischemic heart disease, Epilepsy, Tuberculosis,
Rheumatic heart diseases, Bleeding disorders and STD.
•No h/o dog bite
•No h/o vaccination
•No h/o previous hospitalization
•No h/o surgery
•No h/o blood transfusion

13. Personal History(risk factors
hypertension ,dm, smoking etc)
•Mixed diet
•Normal sleep pattern
•Normal appetite(hyperlipidemia, obesity , pure veg :b12 deficiency, nonveg :
hyperlipidemia and neurocysticercosis)
•No h/o smoking and alcohol consumption
•No h/o drug abuse
•No h/o allergy to (drugs or food
•( menopausal status in females)

14. Family History: No h/o similar illness in the family( hypertension, DM,similar
illness,young death , epilepsy or migraine)
No h/o contact with TB(tuberculoma, tb meningitis,tb arteritis)
Treatment History: The patient is on Anti-hypertensive medications for the
past 10 years and is under control.
No h/o any other drug intake (ocp, antiplatelets, anticoagulants)

16. Summary
•A 65 year old right handed male, Devaraj who is a k/c/o hypertension for past
10 years on regular medication presented with weakness of left upper and
lower limb and deviation of angle of mouth to right side for past 15 days.
•Probable system involved is Central Nervous System.
•Acute Cerebrovascular Accident, which is probably due to thrombosis which
is non-progressive in nature associated with 7th
cranial nerve involvement
and without sensory loss. The probable site of lesion is Right Internal
Capsule.

17. General Examination
The patient is conscious, oriented to time, place and person,
Moderately built and moderately nourished,
Afebrile,
No pallor,
No icterus,
No cyanosis,
No clubbing,
No pedal edema,
No significant generalized lymphadenopathy.

18. Markers
•Neurocutaneous markers: Absent( cafe au lit , pigmented nevi, lish nodules,
shagreen patch, portwine staining)
•Markers of TB: Absent (phlyten, tinea, scrofuloderma, lupus vulgaris)
•Markers of HIV: Absent (candidiasis, herpetic leaions, molluscum
contagiosum, hairy leukoplakia)
•Markers of Syphilis: Absent

19. Vital signs
Pulse rate: 74/min, regular rhythm, normal in volume and character, no
vessel wall thickening, no pulse deficit, no radio-femoral delay and all
peripheral pulses felt
Respiratory rate: 16/min
Blood pressure: 120/80 mm Hg, in right upper arm in sitting posture.
Temperature: 98.4° F
JVP: Not elevated

20. Examination of CNS
Higher Mental Functions:
•Conscious
•Oriented to time, place and person
•Immediate/recent/remote memory intact
•Speech – Normal
•Handedness – Right

21. Cranial nerves
1st
Cranial nerve Right Left
Clove + +
Coffee powder + +
2nd
Cranial nerve Right Left
Visual acuity 6/12 6/24
Colour vision Normal Normal
Field of vision Normal Normal

22. 3rd
, 4th
, 6th
CN Right Left
Extraocular movements Full Full
Pupil- Size 4 mm 4 mm
Reflex
Direct + +
Indirect + +
Accommodation + +
Nystagmus - -
Ptosis - -

23. 5th Trigeminal Right Left
Sensory –
sensation over face
and buccal mucosa
+ +
Motor – Clenching
of teeth
+ +
Reflex – Corneal + +
Conjunctival + +
Jaw jerk +

24. 7th Cranial nerve Right Left
Wrinkling of forehead + +
Frowning of eyebrows + +
Screwing of eyelids + +
Nasolabial fold + Absent
Showing teeth Deviated to right side
Blowing of cheeks + Reduced
Eversion of lower lip + Absent

25. 7th Cranial nerve Right Left
Sensory – Taste in
anterior 2/3rd
of tongue
+ +
Sensation over tragus + +
Reflex – Corneal + +
Conjunctival + +
Secretomotor – Salivation + +
Lacrimation + +

28. 8th
Cranial nerve Right Left
Cochlear-
Rinne’s test
+ +
Weber’s test Heard equally on both sides
Absolute bone
conduction test
Normal Normal
Vestibular - Nystagmus - -
9th, 10th Cranial nerve Right Left
Taste sensation in
posterior 1/3rd
of tongue
+ +
Gag reflex + +
Palatal reflex + +

29. 11th
Cranial nerve Right Left
Shrugging of shoulders + +
Turning head against
resistance
+ +
12th
Cranial nerve Right Left
Tongue protrusion Normal Normal
Fibrillation No fibrillation No fibrillation
Wasting No wasting No wasting

31. Motor System
A. Bulk:
O/I: Normal, no wasting on both sides, no involuntary movements
On palpation Right Left
Upper limb Arm 25 25
Forearm 21 21
Lower limb Thigh 39 39
Legs 30 30

32. B. Tone Right Left
Upper limb Normal Hypertonia
Lower limb Normal Hypertonia
C. Power Right Left
Upper limb Shoulder 5/5 3/5
Elbow 5/5 3/5
Wrist 5/5 3/5
Fingers 5/5 3/5
Thumb 5/5 3/5
Lower limb Hip 5/5 3/5
Knee 5/5 3/5
Ankle 5/5 3/5
Toes 5/5 3/5

35. Reflexes Right Left
Superficial Corneal + +
Conjunctival + +
Abdominal + -
Plantar Flexor Extensor
Deep tendon Jaw jerk +
Biceps jerk + Exaggerated
Triceps jerk + Exaggerated
Supinator jerk + Exaggerated
Knee reflex + Exaggerated
Ankle reflex + Exaggerated

37. Sensory system
Sensation Right Left
Superficial – Touch + +
Pain + +
Temperature + +
Deep – Pressure + +
Deep pain + +
Vibration sense + +
Position sense + +
Joint sense + +

38. Cortical sense
Right Left
Tactile localization + +
Two point
discrimination
+ +
Stereognosis + +
Graphesthesia + +

40. Coordination test
Coordination Right Left
Upper limb – Finger nose
test
+ -
Finger finger nose test + -
Dysdiadokokinesia + -
Tapping in a circle test + -
Lower limb – Heel – knee
test
+ -
Drawing a circle test + -
Foot pad test + -

41. Meningeal irritation
•Neck rigidity – Absent
•Kernig’s sign - Absent
•Brudzinski’s sign - Absent

43. Other system examination
•CVS – S1S2 heard, no murmurs, no added sounds
•RS – Normal Vesicular breath sounds heard, no added sounds
•Abdomen – Soft, non-tender, no organomegaly, no free fluid and normal
bowel sounds heard.
•Spine and cranium: no deformity

44. Diagnosis
A case of Acute Cerebrovascular Accident with left sided hemiplegia in stage
of recovery with left sided UMN type of facial palsy due to thrombosis in
deep penetrating branches of right middle cerebral artery with lesion in right
Internal Capsule with risk factor of Hypertension.

45. Investigations
Routine Investigations:
•Complete Hemogram
•Random Blood Sugar and HbA1C
•Fasting lipid profile
•Blood urea, serum creatinine
•Bleeding time, Clotting time – PT, INR, aPTT
•Serum electrolytes
•Electrocardiogram
•ECHO
•Chest X-Ray PA view

46. •LFT
•RFT
Specific investigations:
•CT scan – Brain
•MRI scan – Brain
•Doppler study of Vertebral, basilar and Carotid System
•MR angiogram and venogram

47. Treatment
•Secure Airway
•Breathing – Ventilation O2 therapy
•Circulation – IV fluids
•Ryle’s tube inserted
•Urine catheterization done
•rTPA 0.9mg/kg to maximum 90 mg; 10% as bolus and remaining over 1 hour
•T. Aspirin 150mg OD
•If allergic to Aspirin, Clopidogrel 75 mg OD

48. • Control of Hypertension : First, 72 hours – If systolic pressure exceeds 220 mm hg
IV Labetalol; After 72 hours – reduced to less than 140/90 mm hg
•Atorvastatin 80 mg HS
•Physiotherapy – to prevent contractures, improve strength and co-ordination
•Stockings – to prevent DVT
•Frequent repositioning – to prevent decubitus ulcer
•Air bed/ alpha bed/ water bed – for rehabilitation
•Bowel care: Lactulose 10 ml HS
•Bladder care: Bed pan/ condom catheters/ invasive catheter
•Occupational therapy to improve motor skills

49. •Speech therapy to improve aphasia or dysarthria
•Anti- hypertensive and other prescriptions should be strictly adhered
•Review visit after 7 days for follow up.

50. THANK YOU!