M.D.

GENERALMEDI
CINE
CASEPROFORMA–CENTRALNERVOUSSYSTEM

Name:
Age/Sex:
Occupati
on:
Address:
Handedness:

HI
STORY

PRESENTINGCOMPLAI
NTS:
Sequenceofev
ent
sint
hepat
ient
’sownwor
ds

HISTORYOFPRESENTI NGI LLNESS:

1.WEAKNESSOFLI MBS
a.Inabi l
itytouset hel i
mbs
b.Onset-Sudden/ insidiousi ncludi ngt hetimeofoccur rence
c.Dur ation
d.Sev erity–par esi sorpar al
y sis
e.Pr ogresion–I fchr onicwhi chl i
mbaf f
ectedf ir
st,t
imei nter valbetweenone
l
imbandanot herl imbandwhet hert hediseasei sst atic,progr essiv
e,
worseni ngori mpr ov i
ng
f. Whichsi deandwhi chl imbi saff ected
1.Upperl imbs
i
) Proximal –combi ngt hehai r,t
aki ngthef oodt ot hemout h
i
i) Distal–but toningt heshi rt,
mi xingthef ood
2.Lowerl imbs
i
) Proximal –squat tingandget t
ingupf r
om t hesquat t
ingposi t
ion,
cl
imbi ngst airsupanddown
i
i) Distal–sl ippingofchappal s,tri
ppingoft oes
g.Whet herthenecki saf f
ect ed–di f
ficult
yi nlif
ti
ngt heheadof fthepill
ows
h.Whet herthet runki saf fected–Rol lingov erthebed, gettingupf rom the
bed
i. Dif
ficultyinbr eathing
j. Whet herther eisanydi urnal v ar
iationi ntheweaknessoft hemuscl es
k.Whet herthel i
mbsar ef l
acci dandl ooseorst if
fandhar d

2.SPINOMOTORSYSTEM
a.Wasting/Thinni
ngofmuscles
b.Pain/fati
gue/musclecramps
c.Fascicul
ations/
muscletwi
tchi
ngs
d.Inv
oluntarymov ement
s–chor ea,
athet
osi
s,t
remor
s,hemi
bal
l
ismus

3.SENSORYSYSTEM
a.sensor
ydefi
cit–abl
etofeel
clot
hes,f
eelinghotandcol
dwaterwhi
lebat
hing
b.numbness/
pinsandneedl
esensati
ons,sensat
ionofwal
kingoncot
tonwool
c.rootpain/neckpai
n/backpai
n
d.bandlikesensati
on/gi
rdl
eli
kesensat
ion
e.unsteadinessonclosi
ngtheeyes/
washbasi
nsi
gn/
abl
etowal
kint
hedar
k
f.Lhermitt
e’ssymptom

4.HIGHERMENTALFUNCTI ONS
a.Lossofconsci ousness/ al
ter
ationinsensor ium –dur at
ion,
compl ete/
part
ial
,aur
a,
associatedwi t
hf it
s,bladder/bowel dist
urbances, r
ecoveryandf r
equencyof
occurrence/fi
ts
b.Speechdi sturbances–aphasi a,slurr
ingofspeech( cerebel
lum),slownessof
speech(extrapyramidal system)/memor y/
sleepdisturbances
c.Delusions/Hal l
ucinations/emot i
onaldisturbances

5.CRANI ALNERVES
I–al t
erat i
oninsmel l
II–blurringofv ision/di
mi nishedv ision,di
fferent
iatecolours,
nightblindness
III
,IV,VI–dr oopi ngofey eli
ds/doubl ev i
sion/abletomov eeyesinall dir
ect
ions
V–hav ingsensat i
onov erthef ace, abletochewf ood
VII–abl et ocloset heey esandl ips, devi
ationofangl eofmout h,dr
ool ingofsali
va,
abletof eel t
asteofobj ects
VIII–har dofhear i
ng,ti
nnitus,ver t
igo
IX,X–di ff
icult
yinspeech, nasal twangt ospeech, r
egurgi
tati
onoff eeds, di
ff
icul
tyi
n
swal l
owing
XI–mov ethenecki nalldirecti
ons, lif
ttheshoulder
XII–abl et orollthetongueandpusht hef oodbackwar ds

6.CEREBELLUM
a.spi
ll
i
ngoff oodwhil
etaki
ngtothemouth,
clumsi
nessofhands
b.unst
eadinesswhi
lewalki
ngandswayingt
osides
c.abi
li
l
tytonegoti
atenarr
owpathways

7.AUTONOMI CNERVOUSSYSTEM
a.bl
adder–abl etof eelbladderfull
ness,ini
ti
atemicturi
ti
on,f
eelthepassageof
uri
ne,abletoholdurinemi dstream,abletocompl etel
yevacuat
ethebladderwit
hout
anydribbing
i
nabil
itytopassurine,catherisati
on
b.bowel –consti
pation,lossofcont roll
eadingtoinvol
untar
ydefecati
on
c.gi
ddinessonget ti
ngupi nthemor ning
d.sweatingdist
urbances, palpi
tati
on

8.MENINGES
Fever
,vomi
ti
ng,
sti
ff
nessofneck

8.RELEVANTNEGATI VEHISTORY:
a.trauma, f
allfr
om height
,li
ft
ingheav
yobj
ect
sont
hehead/
back/spi
nal
anaest
hesia
b.headache
c.v omit
ing,diar
rhoea
d.calftenderness
 e.chestpain
f.drugi
ntake–antihypert
ensiv
es,
oral
cont
racept
ives,
ant
icoagul
ant
s,
vacci
nat
ion,any inj
ecti
ons
j
.bedsor es,dar
kcoloureduri
ne

PASTHI STORY:
a.Si mi l
arill
nessi nthepast
b.TI A/ RI ND
c.Comor bidill
nesslikeDi abetes,Hy per
tensi
on,cor
onar
yar
ter
ydi
sease,
thy roidalil
lness,Tuber culosi
s,HI V,mali
gnancy
d.Tr auma
e.f ev er
f. Dr ugi ntakeandv accinati
onf ordogbi te
g.Pr ev i
ousmedi calil
lness/surgeries
h.Dev el
opment alhi
st ory

PERSONALHI STORY:
a.Mar r
ied
b.Vegornon- veg
c.Sleeppat t
ern
d.Smoki ng
e.Alcohol
f. Dr
ugabuse
g.Exposur e

FAMI
LYHISTORY:
a.Famil
ytree
b.Consangui
nit
y
c.Anyotheraff
ect
edf
ami
l
ymember
s

MENSTRUALHI STORYANDOBSTETRI CHI

STORY–FEMALES:
a.Menar che
b.Regular/I
rregular/
LMP
c.No.ofchildren
d.Fullt
erm/ Preterm/Vagi
nal
/LSCS
e.Obstetri
ccompl i
cati
ons
f. Menopause

TREATMENTHI STORY:
a.Previ
ousTr eat
ment
b.PresentTreatment

SUMMARY:
1.Onset–acut e/subacute/
insi
dious
2.Progression–st atic,r
emitt
ent,inter
mitt
ent,r
apidlyprogressive,sl
owly
progressi
v e,i
mpr oving
3.Disease–Par aplegia/
quadri
plegia/hemipl
egia/
mul ti
plecranialnerve
palsy/ot
her s
4.Structur
esi nvolv
ed–cor tex/brainstem/longtracts/anteri
orhor ncel
ls/
 anteri
ororpost eri
ornerveroots/per
ipheral ner
ves/my oneur
alj
uncti
on/
muscl es/cerebell
um/ ext
rapyr
amidal/autonomi c
5.Levels–Si ngle/Mult
iple
6.Eti
ology–
Trauma/ vascular/
inf
ective/
inf
lammat ory
/ degenerat
ive/
demyeli
nat
ing
/malignancy

PHYSI
CALEXAMI
NATI
ON

GENERALEXAMI NATI ON:

Pat ientisconscious/not
Orient ed/not
Comf ortable/
not
Co- oper ati
ve/
not
Bui l
t
Nour i
shment
Febr il
e/afebri
le
Pal or
I
ct erus
Cy anosi s–cent r
al/
per i
pher al
Clubbi ng–bi lat
eral
/unilateral
,pandigi
tal/
li
mited
Pedal edema–bi l
ateral
/ unil
ater
al,
painless/
painf
ul,
pit
ti
ng(
sof
t/har
d)/
non-
pit
ti
ng,
regional l
ymphadenopat hy
Signi f
icantlymphadenopat hy

SHORTNECK(
Height
/NeckRat
io),
SCARS,BURNS,
DESTRUCTI
ONOFTERMI
NAL
PHALANX,
DECUBITUSULCERS,TROPHI
CULCERS

RI
GHTORLEFTHANDEDI
NDI
VIDUAL,
CATHETERI
SED/
NOT

NEUROCUTANEOUSMARKERS
1.TUBEROUSSCLEROSI S–adenomasebaceum, shagreenpatches,ashleaf
macules
2.NEUROFI BROMATOSI S–caf eulaitspots,neur
of i
bromas,peiungualfi
bromas,
axi
l
lar
yf r
eckl
ing
3.VON- HIPPELLINDAUSYNDROME–conj uncti
valhemangioma
4.STURGEWEBERSYNDROME–por twinestain(
capill
aryhemangioma)
5.ATAXI ATELANGI ECTASIA–telangiect
asias
6.SPINABI FIDA–tuftofhair
7.PHAKAMOTOSES–bi r
thmarks,nevus
8.FRIEDREICH’SATAXI A–pescav us

VI
TALSI
GNS

PULSE: r
ate,r
hythm,volume,charact
er,
fel
tinal
lperi
pher
alpul
ses/not
,
radi
oradi
al/r
adiofemoraldel
ay,apexpul
sedefi
cit
,condi
ti
onofvesselwal
l

BLOODPRESSURE:_
___
_mm ofHgmeasuredi
nthe__
___Upperl
imbwit
hthepat
ient
i
nsit
ti
ngposi
ti
onand____
__mm ofHgi
nthest
andi
ngposi
ti
on.Lookf
orPost
ural
Hy
pot
ensi
on

RESPIRATORYRATE:___
_/min,regul
ar/
not
,ty
pe-
thor
acoabdomi
nal
/abdominothoraxi
c

TEMPERATURE:
___
___Fmeasur
edi
ntheAxi
l
la

NEUROLOGI
CALEXAMI
NATI
ON

1.HIGHERMENTALFUNCTI ONS:
a.Consci ousness
b.Or i
entat i
ont otime, placeandper son
c.Speechandl anguage– aphasi a,dysart
hri
a,dysphoni
a
d.Memor y–i mmedi ate- retentionandr ecal
l,
recentandremote
e.Del usions, hall
uci nat i
ons
f. Emot i
onal labilit
y
g.MMSEscor e
I
.Or i
ent ation
1.dat e, day ,mont h, season, y
ear(5)
2.floor ,hospi tal.Di stri
ct ,
st at
e,country(
5)
I
I.Regi stration
Namet hr eeobj ect st akingonesecondf oreachobject
.Askhi
mtor
epeat
thesame.
Repeatt illher emember s( 3)
I
II.AttentionandCal cul ation
Serial7’s5t imes( 5)
I
V.Recal l
Recal lthet hreeobj ect s(3)
V.Language
1.Name2obj ect s( 2)
2.Repeatasent ence( 1)
3.Fol l
owa3st agecommand( 3)
4.Readi ng“ cl
osey ourey es”(1)
5.Wr it
ingasent ence( 1)
6.Copyadesi gn( 1)

2.CRANIALNERVES
CRANIAL TEST RI
GHT LEFT
NERVE
I Senseofsmel l
i
) Coff
ee +/- +/-
i
i) Asafoeti
da +/- +/-
II i)Visualacuit
y–Rosenbaum Char t 20/20 20/20
i
i)Fiel
dofv i
sion–Confront
ationtest Normal Normal
i
ii
)Colourvision–Ishi
harachart Normal Normal
i
v)Fundus Normal Normal
II
I,I
V,VI i
) Ext
ra-ocul
armovements ful
l ful
l
i
i) Pupil–Size mm mm
 i
i
i) Di r
ectLightRefl
ex Present Pr
esen
i
v) Consensual LightRef
lex Present t
v
) Accommodat ionRefl
ex Present Pr
esen
v
i) Ptosis Absent t
v
ii
)Ny stagmus Absent
v
ii
i)Hornerssyndrome No Absent
Absent
No
V i
)Sensory-
overfaceandbuccal mucosa Nor
mal Normal
i
i)Motor–masset er,t
emporali
s, Nor
mal Normal
pter
ygoi
ds
i
ii
)Refl
ex Pr
esent Pr
esen
a.Corneal Refl
ex Pr
esent t
b.ConjunctivalRef
lex Pr
esent Pr
esen
c.Jawj erk t
Pr
esen
t
VI
I i
)Motor–
nasol abialfold Present Presen
hy er acusi s Absent t
occi pitofrontalis Good Absent
or bicul arisocul i Good Good
or bicul arisor i
s Good Good
bucci nat or Good Good
pl aty sma Good Good
i
i)Sensor y– Good
Tast eofant erior2/3r
dsof Nor
mal
t ongue( salt/sweet) Nor
mal
Sensat ionov ertragus Nor
mal
i
ii
)Reflex– Nor
mal
Cor neal Pr
esent
Conj unct ival Pr
esent Pr
esen
i
v)Secret omot or– t
Moi st nessoft heeyes/t
ongue Nor
mal Pr
esen
andbuccal mucosa t

Normal
VI
II i
)Ri
nnesTest Posi
ti
ve Posi
ti
v
i
i)Weber
sTest Not e
l
ater
ali
sed

i
i
i)Ny
stagmus Absent
Absent
I
X,X i
)Uvul
a,Palat
alarches,
andmov
ement
s Central
l
y
pl
acedand
symmet ri
c
al
i
i)Gagrefl
ex Presen
i
ii
)Palat
alref
lex Present t
Present Presen
 t
X1 i
)tr
apezius Good Good
i
i)ster
noclei
domastoi
d Good Good
XI
I i
)Tone Normal Normal
i
i)Wasting No No
i
ii
)Fibri
ll
ati
on No No
i
v)TonguePr ot
rusi
ontot
hemi
dli
neand Normal Normal
ei
therside

3.MOTORSYSTEM
TEST RI
GHT LEFT
I–BULK
a.Inspect
ion Nor
mal Nor
mal
b.Palpati
on Nor
mal Nor
mal
c.Measur ement
s
Upperlimb–10cm aboveandbel
owacromi
on cms cms
Lowerlimb18cm aboveand10cm bel
owti
bial cms cms
tubercl
e
II–TONE
a.Upperlimbs Normal/
ri Normal/r
b.Lowerlimbs gi
dity
/sp igidi
ty/
s
ast
ici
ty past
ici
ty
I
II–POWER
a.Neckmuscles Good Good
b.Upperl
imbs
i
) Shoulder 5/
5 5/
5
Fl
exion- Extension 5/
5 5/
5
LateralRot ati
on-Medi
alRotat
ion 5/
5 5/
5
Abduct i
on- Adduction 5/
5 5/
5
i
i
) Elbow
Fl
exion- Extension 5/
5 5/
5
i
i
i) Wr i
st
Dorsi f
lexion-Palmarfl
exi
on 5/5 5/5
Abduct i
on- Adducti
on 5/5 5/5
Pronation-Supinati
on 5/5 5/5
iv) smal lmuscl esofhand Good Good
v) Handgr ip Good Good

c.Lowerl
imbs
i
) Hip
Flexion-Extension 5/
5 5/
5
Abduct ion-Adduct i
on 5/
5 5/
5
Lateral Rotati
on- Medi
alRotat
ion 5/
5 5/
5
i
i) Knee
Flexion-Extension 5/
5 5/
5
i
ii
) Ankl e
Dor sifl
exion-Plantarf
lexi
on 5/5 5/5
Inversion-Eversion 5/5 5/5
i
v) Smal lmuscl esoff oot Good Good
 d.Trunkmuscl
es Good Good
e.Beevor
’ssi
gn Absent Absent

I
V–REFLEXES
A.SUPERFI CIALREFLEXES
1.Cor neal Pr
esent Pr
esent
2.Conj unct i
val Pr
esent Pr
esent
3.Phar yngeal Refl
ex Pr
esent Pr
esent
4.Palat alReflex Pr
esent Pr
esent
5.Abdomi nal Reflex Pr
esent Pr
esent
6.Cremast ericRef l
ex Pr
esent Pr
esent
7.Per i
anal Ref lex Pr
esent Pr
esent
8.Plant arRef lex Fl
exor Fl
exor
B.DEEPTENDONREFLEXES
1.Jawj erk Present
2.Trapezi usj erk Present Present
3.Pect oralisjerk Present Present
4.Bicepsj er k Present Present
5.Tricepsj erk Present Present
6.Supi natorjer k Present Present
7.Fingerf lexionreflex Present Present
8.Kneej erk Present Present
9.Ankl ejerk Present Present
10.
Clonus Absent Absent

C.PRI
MITI
VEREFLEXES Absent Absent

D.OTHERS
Hoffmanssign Absent Absent
Wartenber
gssign Absent Absent
Rossali
mossign Absent Absent
Absent Absent
V–COORDI NATION
TESTEDALONGWI THTHECEREBELLUM
VI–GAI T
VII–I
NVOLUNTARYMOVEMENTS
A–At het osi
s,Asterexi
s
B–Bal l
ismus
C–Chor ea
D–Dy stoni a
E–Essent i
altr
emor s
F–Fasci culati
ons
M -Myocl onus

4.SENSORYSYSTEM
TEST RI
GHT LEFT
I–SPINOTHALAMIC
1.Crudet
ouch Nor
mal Nor
mal
2.Pain Nor
mal Nor
mal
 3.Temper ature Nor
mal Nor
mal
I
I–POSTERI ORCOLUMN
1.Finetouch Normal Normal
2.Vibrati
on Normal Normal
3.Positi
onsense Normal Normal
4.Romber g’
ssi gn Absent Absent
I
II–CORTICAL
1.Twopoi ntdi scri
minat
ion Nor
mal Nor
mal
2.Tactil
elocalisati
on Nor
mal Nor
mal
3.Graphaest hesia Nor
mal Nor
mal
4.Stereognosis Nor
mal Nor
mal

5.CEREBELLARSI GNS
1.Ti t
ubat i
on
2.Tr uncalataxia/gai
tataxi
a/stanceataxia
3.Ny stagmus
4.Dy sarthri
a
5.Hy potonia
6.Reboundphenomenon
7.I nt
enti
ont remor
8.Pendul arkneej erk
9.Tandem Wal king
10.Coordinati
on
a.UpperLi mbs–Fi ngerNoset est
,FingerFi
ngerNoset
est
,Dr
awi
nga
ci
rcle,Putti
ngadoti nthecentreofthecir
cle
b.LowerLi mbs–Heel Kneetest,Drawingacir
cle
c.Dy sdiadokokinesi
a

6.AUTONOMI CNERVOUSSYSTEM
Postur
alHypotensi
on
Rest
ingtachycar
dia
Abnormalsweating

7. SI
GNSOFMENI NGEALI
RRI
TATI
ON
Neckstif
fness
Kerni
g’ssi
gn
Brudzi
nski’
ssign

8. EXAMINATI
ONOFTHESPI NEANDCRANI UM
SPI
NE–bonydef or
miti
es,
bruit,
gibbus,
tender
ness
CRANIUM –bonyabnor
malit
ies,br
uit

9. PERIPHERALNERVES
Thickenedner
ves
Trophicul
cers
Wr i
stdrop
Footdrop

10.CAROTI
DPULSESANDBRUI
T
 EXAMI
NATI
ONOFOTHERSYSTEMS

CARDI OVASCULARSYSTEM:
JVP, Apexnor
mall
ypl
aced,noPal
pabl
eP2,
Hear
tsounds–nor
mal
,No
thr
il
ls/murmurs

RESPIRATORYSYSTEM:
Chestsymmetri
cal
,Noparadoxi
cal
mov
ement
s,Nor
mal
vesi
cul
arbr
eat
hsounds
hear
d,
Noabnormal/
addedsound

ABDOMEN:
Abdomeni
ssof
t,Noor
ganomegal
y,Noasci
tes,
Per
-r
ect
alexami
nat
ion

DI
AGNOSI
S

I
NVESTI
GATI
ONS

TREATMENT

_
___
___
_