I

MD POSTGRADUATE-CLINICAL
.& •ANNUAL•
~ -
NEUROLOGY TEACHING COURSE-2022 .
GOVT. CHENGALPATTU MEDICAL COLLEGE HOSPITAL

CNS PROFORMA

Occupation Handedness
Age Sex
Name

Informant
Education status

Chief compla ints : (In chronological order)

1:

2:
3:
HOPL : ( Elaborating the presenting complaints)

l)Weakness -duration,mode of onset (insidious/slowly progressive /acute),time of occurrence{during

work/sleep),symmetrical/asymmetrical, progression (initially difficult and now unable to do-·static/
progressive/ recovering),diurnal variation.
2)unsteadiness-duration,mode of onset,persistent or transient,aggravated in the dark,associated wit h
giddiness/involuntary movements,accompanied by falls or not,tends to fall on which side-forward or
lateral.
3)Giddiness-duration,mode of onset,progression,intermittent/continuous,time of occurrence(early
morning),associated with vomiting or transient visual obscurations,swaying to which side.
4)speech disturbance-in the form of,duration,mode of onset,progressive/non progressive,diurnal variation

Motor system:
H/o slippers slipping while walking (intrinsic muscles)

(Aware slippage-isolated motor;

Unaware slippage-isolated sensory or sensory motor)

H/o tripping over toes while walking (dorsiflexors of toes+ spasticity) distal muscles of LL
H/o difficulty in toe walking (plantar flexors of foot)

H/o tip-toe walking (dorsiflexors of foot)

H/o difficulty in clearing the obstacles in ground( dorsiflexors of foot)

H/o buckling of knees while walking (knee extensors-quadriceps )

H/o difficulty in getting up from squatting posture {knee & hip extensors)

H/o difficulty in getting up from chair (knee & hip extensors)

proximal LL
H/o difficulty in climbing upstairs & downstairs (Hip and knee extensors )

H/o difficulty in rolling in the bed {trunk muscles)

H/o difficulty in buttoning & unbuttoning the shirts {intrinsic muscles}

H/o spillage of food while taking food(intrinsic muscles of hand}

H/o difficulty in writing

H/o difficulty in mixing the food while eating (i ntri nsic muscles of hand} distal UL

H/o difficulty in holding objects in the hand (forearm flexors}

H/o difficulty in using the left hand for toilet purpose

H/o difficulty in combing the hair (shoulder girdle muscles} proximal UL

H/o difficulty in raising the arm above shoulder (shoulder girdle muscles}

H/ o difficulty in bringing food t o the mouth

H/o difficulty in raising the head from pillow in prone position (neck extensors)
I
H/o difficulty in raising the head from pillow in supine position (neck flexors}

H/o difficulty in holding head in upright posture while sitting (neck muscles}

H/o abnormal muscle bulk

H/o abnormal posture {dystonia}

H/o stiffness {UMN}

H/o flailness/thinning /twitching/wasting (LMN}

H/o agonising pain(cramps} in the body

Motor extrapyramidal symptoms-slowness ,tremulousness, postural instability

H/o tremulousness (extrapyramidal/cerebellum}

If cerebellum-h/o worsening while reaching objects// h/o spillage of food while reaching mouth

If weakness presents look for associated features

Flailness/stiffness-lmn/umn

Wasting-lmn

Diurnal variation-NMJ vs others

Cramps-neurogenic/myogenic

Muscle pain-inflammatory myopathies

Abnormal shortening of muscles-{contractures-muscular dystrophys)

Triggered by exercise-metabolic myopathies

Spontaneous muscle twitching(fasciculations/myokymia-neurogenic)

Sensory system:

H/o pain-localised/referred/radicular/furiicular (positive symptom)

( radicular-radiating pain, funicular-vague .dull aching,localised)

 H/o numbness (negative symptom) - larger fiber sensatio n)
h'I lking (sensory )
H/o difficulty in holding the slippers w I e wa . n}(posit ive sympto ms
. mall fiber sensat10
H/o pins & needles / burning sensation of feet (s

H/o able to perceive t he clot h sensation . e body

. in both sides of th
H/o difference in perceiving temperature sensation

H/o appreciation of insect bite

. . . ( all fiber sensation)
H/o able to perceive hot/cold sensation while bathing sm
lination ))
. . . lumn involvem ent/dem ye
H/o electric shock like sensation (LhermIttes sign - posterior co
H/o band like sensation in trunk (sensory tract at cord)

Posterior column

H/o unsteadiness while washing the face

H/o feeling the ground like cotton wool while walking with bare foot

H/o incoordination in the dark

CRANIAL NERVES

H/o loss of smell(l) ( unilateral-neurological/bilateral-local cause)

H/o difficulty in seeing objects in one half either right/lef t (field defects- hemiano
pia)(2)
h/o bumping over objects while walking (Hemianopia) (2)

H/O defective vision to distant object/c olour objects(2)

H/o double vision while seeing on both eyes (diplopia - 3,4,6)

} oblique or recti weOkness
H/o difficulty in moving eyeballs in all direction (squint - 3,4,6)

H/o drooping of the eyelids (Horner's/3th/myogenic)

H/o difficulty in chewing the food/ drooping of the jaw (5 t h motor/m yogenic )

H/o difficulty in appreciating the sensation over the face (5)

H/o deviatio n of angle of mouth to rt/It side (7)

H/o dryness /abnorm al watering in the eye(7)

H/o drooling of saliva while drinking /eating (7)

H/o hard of hearing /tinnitus / vertigo (8)

H/o difficult y in swallow ing the food(liquids/solids) {9,l0()liquid-neurogenic)

H/o chockin g sensatio n while eating (9,10)(-pharyngeal muscles)

H/o hoarsen ess of voice (9,10)

H/o nasal regurgit ation while drinking (9,10)

h (g lO)-(pha ryngeal and laryngeal muscles)

H/o nasal speec ,
7 > "
H/o difficulty i.n turning the head from side to side (11)

' H/o d1ff1culty m shrugging the shoulder (11)

H/o difficulty in protruding the tongue (12)(extrinsic tongue muscles)

H/o difficulty in rolling the tongue from side to side/manipulating the food(12)

Bladder & autonomic system

H/o able to perceive bladder fullness I·

H/o able to initiate micturition at will·I

H/o frequency of micturition / urge incontinence of urine/nocturia (UMN}

H/o incomplete bladder emptying after voiding (LMN}

H/o hesitancy(LMN)

H/o any interrupted stream of urine

H/o erectile dysfunction (LMN)

H/o bowel incontinence/altered bowel movements

H/o constipation

H/o abnormal sweating /dryness of skin/hair loss {skin,hair,nail changes}

H/o postural giddiness

(compressive myelopathy - early bladder & bowel disturbance; non-compressive - late except in

ATM)
(lntramedullary- early bladder & bowel disturbance;Extramedullary-late)

Cerebellar

H/o unsteadiness while standing (stance ataxia)

(h/o unsteadiness may be cerebellum/sensory/vestibular)

H/o difficulty in negotiating narrow pathways (gait ataxia)

H/o spillage of food around the plate while eating (ataxia of limbs)

H/o spillage of water while drinking (ataxia of limbs)

H/o smashing the food on the face while eating (ataxia of limbs)

H/o speech disturbances (dysarthria}

H/o oscillations of objects while seeing (nystagmus symptom-Oscil\opsia)

H/o involuntary movement

 Extrapyramidal system

H/o involuntary movements

H/o stooped posture
H/o diminished arm swinging
HIGHER MENTAL FUNCTION:

H/o speech /memory disturbance

H/oloc
H/o behaviour & emotional disturbance

H/o sleep disturbances

H/o delusfon and hallucinations

H/o seizures

OTHER ETIOLOGICAL HISTORY:

H/o headache/ raised ICT features

h/o fever/vomiting/ne ck stiffness

h/o trauma h/o loss of wt/appetite

Past history:

No H/o similar complaints in the past (relapsing illness - MS/CIDP; Toxin related/nutritiona l related)

No H/o suggestive of preceding fever/diarrhoea/dy suria/cough with expectoration (demyelinating)

No H/o suggestive of chronic illness like HIV/SYPHILIS/TB/ malignancy

No H/o DM /HTN/CKD/DYSTHYROID state

Treatment history

No significant treatment history (demyelinating/ stroke/neoplasm)

Personal history

Smoker/ alcohol/ sexual promiscuity.

Family history:

Family tree in inherited / degenerating disorders

Socio-economic history:

Summarise your presentation:

Discuss: structures involved/then localisation/lastly etiology /DDs

,
 EXAMINA TION OF CNS

General examinati on:

Built , nourishment

Conscious /oriented

No pallor /icterus/cyanosis/clubbing/lymphadenopathy/pedal edema

JVP

Neurocutan eous, TB, ishemic heart disease markers

Vitals :

BP/ PR/ Temp/ RR /single breath count (sbc)/postural hypotensio n

(RR - in GBS, high cord lesion),(sbc-high cord/GBS/brainstem cases/MND)

Height-neck ratio-high cord lesion

HIGHER MENTAL EXAMINAT ION:

MMSE-

Handedness-

Consciousness-

Orientation to time/place /person

Memory - immediate , recent & remote

Speech /Language - comprehen sion, fluency, repetition

Emotional liability
 CRANIAL NERVE EXAMINATION:

LEFT
NERVES RIGHT
Able to perceive smell
OLFACTORY Able to perceive smell

OPTIC NERVE

l)vis ual acuity 6/6

6/6

2)field of vision Full range Fu II range

3)colour vision Norm al

Normal
4)fundus

3, 4&6 :

l)ex tra ocular movements

Full range Full range
2)dir ect & indir ect light reflex
Present Present
3)Ptosis

4)ac com mod ation reflex

TRIGEMINAL NERVE

l)sen satio n over face & buccal mucosa

Present
Present
2)clenching of teet h
No deviation
No devi ation
3)corneal & conjunctiva! reflex
Present
Present
4)ja w jerk
Present
Present
FACIAL NERVE

l)Ta ste in ant 2/3 of tong ue

Present
Present
2)sensation over the tong ue
Present
Present
3)wr inkli ng of fore head
Present
Present
4)op enin g eye agai nst resistance
Present
Present
S)de viati on of angle of mou th

6)bl owin g of cheeks & hold ing of air in

mou th Pres ent Present
 ?)corneal & conjunctiva! reflex

8)salivation & lacrimation

Present Present

Present Present

VEST! BU LO-COCH LEAR NERVE

l)Rinne's test(BC>AC)

2)Weber's ( lateralisation)

GLOSSOPHARYNGEAL & VAGUS:

l)Sensation over post 1/3 of tongue Present Present

2)position of uvula Midline M idline

3)palatal & pharyngeal reflex Present Present

SPINAL ACCESSORY NERVE:

l)Shrugging of shoulder against resistance Present Present

2)turning head against resistance Present Present

HYPOGLOSSAL NERVE :

l)Deviation of tongue on protrusion

2)Fibrillation / wasting

3)Power

4)spastic/flaccid

MOTOR SYSTEM EXAMINATION:

Generalised /localised muscle wasting

l)BULK:

ICIRCUMFERENCE I RIGHT (cm) ILEFT(cm)

r; - - - - - -
~----r--;M-;;-;i;d-;;a;;rm ; ; - - - - - - i - - - - - - - - - r - - - - -

Mid forearm

Mid thigh
LOWER LIMB

Mid leg

UL- 10 cm above and below the ol'ecranon process

LL-18 cm above the superior border of patella

10 cm below tibial tuberosity

To look for fasciculation/muscle tenderness

2)TONE:

RIGHT LEFT

UPPER LIMB

LOWER LIMB

3)POWER:

RIGHT LEFT

SHOULDER: Flexion,extension,adduction,abduction

ELBOW: Flexion, extension , supination ,pronation

WRIST: Flexion, extension, adduction, abduction

FINGER: Flexion, extension, adduction, abduction

THUMB: Flexion, extension,adduction, abduction,opposition

HIP : Flexion, extension, adduction, abduction, rotation

KNEE: flexion, extension

ANKLE: dorsioflexion, plantar flexion, inversion, eversion

TOES: Flexion , extension, adduction, abduction

4)REFLEX:

SUPERFICIAL RIGHT LEFT

Corneal (5,7)

Conjunctiva! (5, 7)

Pharyngeal (9,10)

Palatal(S,10)

Abdominal (T8-T12)

Cremastric (Ll,L2)

Plantar(LS,S1)

DEEP REFLEX RIGHT LEFT

Jaw jerk(CS)

Biceps(CS,C6)

Triceps(C6,C7)

Supinator(C5,C6)

Knee (L2,L3,L4)

Ankle(S1)

If knee/ankle DTR exaggerated look for clonus. If diminished/absent do jendrassik method

 reflex
Hoffmann's reflex, Wartenberg's
OTHERS - Finger flexor reflex,

out reflex/glabellar)
thing(in old age-pa Imo mental/sn
Cortical release reflexes: if any

6)COORDINATION:
I LEFT -- i
RIGHT
I UPPER LIMB -
Finger nose test

Finger finger nose test

Dysdiadochokinesia

LOWER LIMB

Heel knee test

Drawing a circle

7)/NVOLUNTARY MOVEMENTS:

SENSORY SYSTEM : I
I LEFT
RIGHT
SUPERFICIAL

Touch

Pain

Temperature

DEEP

Pressure

Deep pain

Vibration

Position sense

CORTICAL SENSATION

Tactile localisation
 rwo point discrimination

stereognosis

- Graphaesthesia

CEREBELLUM:

Dysdiadochokinesia

Oysmetria

Ataxia

Nystagmus

Intentional tremors

Staccato/scanning speech \

Hypotonia

pendular knee jerk

Titubation

Rebound phenomenon

MENINGES:
Neck rigidity, kernig's, brudzinki's sign

ROM BERG'S:

GAIT:

SPINE & CRANIUM:

PERIPHERAL NERVE: thickening/tenderness

OTHER SYSTEM:

CVS:

RS:
 ABDOMEN:

DIAGNOSIS: STRUCTURE INVOLVED

LOCALISATION -

ETIOLOGIES/ODs

INVESTIGATIONS :

MANAGEMENT:
 Sp in al Co rd P·a th wa ys
Descending
Ascending
Posterior colu mni Sacral I
Pathways
Pathways Lumbar 1 Gracile fascicu lus
Thoracrc
Cervical
1 _j_. _j_Cunea te fascicu l us
I
lateral
,r._ __..,,--Sacral rticospinat
~':),:-......,~L umb tract
Thor
Cervical

_Lateral
Sa::aorar
sp1nolhalam
tract Cervica Anterio r
Anteri0 t
oortlcospinal
spinothalamic tract
tract

© Lineage Moise s Domingue:z

SPINAL CORD LEVEL CORRESPONDING VERTEBRAL LEVEL

Cerv ical Same as cord level Cl-C 4

1 level highe r CS-T4

Lowe r cervi cal

2 level highe r T4-T6

Uppe r thora cic

2-31evel highe r T7-T9

Lowe r thora cic

T10-T12
Lumb ar

T12- Ll
Sacral