CNS CASE PROFORMA

NAME
AGE
SEX
ADDRESS
OCCUPATION

CHIEF COMPLAINTS:

HISTORY OF PRESENTING ILLNESS:

 Weakness-

Onset
duration
progression
trunk muscles – rolling over bed.getting up from bed
neck muscles - raising head and holding neck
parts involved- UL &LL
Proximal weakness:
UL-Difficulty in combing hair
LL-Difficulty in getting up from Squatting
Distal muscle weakness:
UL-Difficulty in buttoning & unbuttoning
 LL-Difficulty in gripping chappals
 Associated symptoms: Stiffening of limbs
Giving away
Involuntary movements-fasciculations,twitching,tremors.
Speech disturbance
 CRANIAL NERVE SYMPTOMS
 OLFACTORY-H/O Disturbance of smell
 OPTIC-H/O Visual disturbance
 3rd,4th,6thNERVES-H/O Diplopia, Squint, Ptosis
 TRIGEMINAL-H/O Difficulty in eating, unable to feel
sensations over face
 FACIAL-H/O Drooling of saliva, deviation of angle of
mouth, inability to close eyes, loss of taste sensations
 VESTIBULO COCHLEAR-H/O Disturbance in hearing,
vertigo , tinnitus
 Glossopharyngeal & vagal -H/O Nasal regurgitation of
feeds, nasal twang to speech & difficulty in swallowing
 Spinal accessory -H/O Difficulty in turning head side to
side
 Hypoglossal - H/O Difficulty in making bolus of feeds &
H/O Dysarthria
 SENSORY DISTURBANCE:
Onset
Duration
Progression
 Parts of body involved:
One half-hemi anaesthesia
Only extremities-glove & stock syndrome
Entire limb
h/o rootpains- dermatomal distribution
aggravating factors,nature of pain
Type of sensory disturbance
H/O band like sensation over torso
H/O wash basin attacks
Difficulty walking in dark
 CEREBELLAR SYMPTOMS: apraxia
Difficulty in taking food to mouth
Difficulty in buttoning
Swaying while walking / reeling sensation.
 SPHINCTERIC DISTURBANCES:
BLADDER: Retention of urine
Difficulty in initiation-Hesitancy
Difficulty in controlling- precipitancy
Incontinence / dribbling
BOWEL: Constipation
Incontinence
Diarrhoea
SEXUAL: Impotence
Retrograde ejaculation

h/o loose stools,diarrhoea

 H/O Recent cardio - respiratory symptoms
H/O Fever, headache, vomiting, Blurring of vision,loss of
consciousness / altered sensorium.
RaisedICT features

H/O Trauma , convulsions

H/O vaccinations/ exanthematous fevers ADEM
H/O loss of appetite, loss of weight
 OTHER SYSTEMS SYMPTOMATOLOGY: CVS , RS , GIT
 PAST HISTORY:
Any dehydrating illness, CVS & RS illness
Any similar history in the past
H/O Systemic HTN, DM, BA, TB, HIV,Neurosyphilis,HIV,Blood
transfusion,head injury,epilepsy,TIA,dog bite,anti rabies
vaccination, any malignancy,chemotherapy,radiotherapy

 PERSONAL HISTORY:
Diet, smoking, alcoholism, exposure to STD’s ,promiscus
behaviour, bowel & bladder habits, sleep & appetite
 MENSTRUAL HISTORY:
History of usage of OCP’s
 FAMILY HISTORY: similar history in the family, nutritional
disorders, ataxia , lathyrism, B12, Flourosis, TB, CVA
 GENERAL EXAMINATION:
Built & Nourishment
 Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal oedema
Any wasting &Neuro cutaneous markers
Markers of HIV , TB, Neurosyphilis
Penile scars
H/O injuries , burns , rash over body
 VITAL SIGNS: PR
BP
RR
TEMP
JVP
Carotid bruit
 CNS EXAMINATION

HIGHER MENTAL FUNCTIONS:

Handedness
Conscious & co-operative
Orientation to Time , Place , Person
MEMORY- Immediate, Recent , Remote
SPEECH: Fluency , Comprehension , Naming , Repetition ,
 Writing , Reading
 CRANIAL NERVES

1st CN-Smell sensation in each nostril

2ndCN- Visual acuity- Near & Distant
Colour Vision
Field of vision
3, 4, 6 CN- Extra ocular movements-Both individual eyes
Presence of Nystagmus
Pupils- size
Light reflex- Direct & Indirect
5th CN- Superficial skin sensation over face
Test for Muscles of mastication
7th CN –Taste sensation over anterior 2/3rd of tongue
Muscles of facial expression
8th CN- Test for acuity of hearing with fingers
Rinne’s test
Weber’s test
Absolute bone conduction test
9th CN- Gag reflex- afferent
10th CN- Palatal reflex
Gag reflex – efferent
IDL- Vocal cord movements
11th CN- Turning head against resistance
 Raising head forward against resistance
Shrugging of shoulders against resistance
12th CN- Atrophy & movements of tongue/fibrillation
 MOTOR SYSTEM
Attitude of limb
Nutrition
TONE- Hypotonia/ hypertonia- spasticity,rigidity.
Power- UL- neck and trunk
Shoulder- Abduction
Adduction
Flexion
Extension
Internal rotation
External rotation
Elbow- Flexion
Extension
Wrist- Flexion
Extension
Hand grip – small muscles
LL- Hip- Abduction
Adduction
Flexion
Extension
rotation
 Knee- Flexion
Extension
Ankle- Dorsiflexion
Plantar Flexion
Inversion and eversion
REFLEXES:
SUPERFICIAL-
Corneal,
conjunctival,
abdominal,
cremasteric,
plantar
release reflexes
sphincteric reflexes anal and bulbocavernous

DEEP –

Jaw jerk,

triceps,
biceps ,
supinator ,
knee ,
Ankle

CO-ORDINATION- UL- fnt,ffn , LL- knee heel.

 INVOLUNTARY MOVEMENTS
GAIT
 SENSORY SYSTEM

EXTEROCEPTIVE-
Touch ,
Pain ,
Temperature
PROPRIOCEPTIVE –
Vibration ,
Joint position sense
ROMBERGS SIGN

CORTICAL SENSATIONS – Tactile localisation,

Two point discrimination,

stereognosis ,

Graphaesthesia.

 CEREBELLAR SIGNS
 Nystagmus
Titubation
Scanning Speech
Hypotonia
Intention tremors/ over shooting
Dysdiadochokinesia
Rebound phenomenon
Limb incordination
Knee Heel test
Past pointing
Tandem walking
 ANS :Orthostatic BP
HR Variation with posture,perspiration
 MENINGEAL SIGNS:
Neck stiffness
Kernig’s sign
Brudzunki’s sign
Skull and spine- swelling, deformity,
 OTHER SYSTEMS:
CVS
RS
Abdomen
 DIAGNOSIS: Clinical diagnosis
Functions- mono hemi para quadriplegia
Pathological Diagnosis
Anatomical Diagnosis
Etiological Diagnosis