CNS CASE PRESENTATION

Dr NAVEEN.M ,
FINAL YEAR POST GRADUATE
Dr SANGEETHA.T,
FINAL YEAR POST GRADUATE
CHIEF COMPLAINTS
• A 65 year old female Mrs Anthonyammal from Thoothukudi ,
day labourer by occupation ,Right handed person came with
the chief complaints of,
o Slurring of speech for 4 days
o Difficulty in using the Right upper and lower limb for 4
days
HISTORY OF PRESENT ILLNESS
• The patient was apparently normal before 4 days after which she
developed,
• Slurring of speech which was acute in onset, associated with drooling
of saliva on left side ,which she noticed while returning from work
• H/O difficulty in Right Upper and lower limb for 4 days which was
Acute in onset, static nature, which she started noticed weakness in
both upper and lower limbs simultaneously after 6 hrs of developing
slurring of speech, came to hospital next morning
• H/O difficulty in insinuating toes into slippers
• H/O Tripping of toes while walking.
• H/O difficulty in getting up from squatting position
• H/O difficulty in getting up from the chair
• No H/O difficulty in rolling in bed from side to side.
• H/O difficulty in hooking the dresses.
• H/O difficulty in mixing the food while eating
• H/O difficulty in combing the hair
• H/O difficulty in raising the arm above the shoulder
• H/O difficulty in bringing food to mouth
• No H/O difficulty in raising the head from the bed in prone position
• No H/O difficulty in raising the head from the pillow in supine position
• No H/O difficulty in neck holding while sitting
• No H/O wasting, twitching, flailness of limbs
• Diminished perception of cloth sensation on Right side
• Not Able to perceive hot sensation on right half of body
• No H/O electric shock like sensation
• No H/O pins and needle sensation
• No H/O unsteadiness while washing the face
• No H/O incoordination while closing eyes
• No H/O loss of smell
• H/O difficulty in seeing objects in right side
• No H/O difficulty i n perceiving colors
• No H/O double vision, blurring of vision, drooping of eyelids
• No H/O difficulty in moving the eyeball
• No H/O difficulty in chewing the food
• No H/O difficulty in appreciating sensation in the both half of the face
• H/O deviation of angle of mouth towards right
• H/O drooling of saliva
• No H/O hard of hearing, tinnitus or spinning sensation of head
• H/O difficulty in swallowing
• H/O nasal regurgitation while drinking
• No H/O difficulty in turning head from side to side
• H/O deviation of tongue towards left side
• H/O difficulty in mixing food in mouth
• H/O difficulty in protruding tongue
• H/O difficulty in negotiating narrow pathway.
• No H/O smearing of food over face while eating
• No H/O spillage of food around the plate while eating.
• No H/O spillage of water while drinking.
• No H/O increased frequency ,urgency of urine
• No H/O interrupted stream of urine.
• No H/O feel of incomplete evacuation.
• No H/O hesitancy.
• No H/O altered bowel movements.
• No H/O excessive sweating, palpitation at rest or postural giddiness.
• No H/O loss of consciousness
• No H/O involuntary movements of upper and lower limbs
• No H/O behavioural abnormalities/memory disturbances
• No H/O Trauma
• No H/O loss of weight and appetite.
• No H/O headache, vomiting or neck stiffness.
• No H/O evening rise of temperature or night sweats.
• No H/O cough with expectoration.
• No H/O dog bite.
PAST HISTORY
• K/C/O T2DM for 15 Years not on regular Rx.
• N/K/C/O SHTN, TB,CAD, CKD, Thyroid, HIV, Syphilis.
PERSONAL HISTORY
• Consumes non veg and veg diet.
• Normal sleep & appetite.
• No H/o blood transfusion/ drug allergy
• No H/o any high risk sexual behaviour
FAMILY HISTORY
• No similar illness in the family members
• A 60 year old female ,k/C/O Type 2 Diabetes Mellitus came with
• Acute onset of right side hemiparesis
• With loss of pain and temperature sensations on right side
• With involvement of 7th nerve –drooling of saliva
• With involvement of 12th nerve –difficulty in mixing food
• Without bowel or bladder involvement ,cerebellar ,extra pyramidal
and preserved higher mental function
• TRACTS INVOLVED : Left corticospinal tract
• Left spinothalamic tract
• 7th nerve
• 12th nerve
MOST PRABABLE STRUCTURE INVOLVED - PONS
• Patient is conscious and cooperative
• Oriented to time, place and person
• Right handed individual
• Moderately built and nourished
• No pallor, icterus, cyanosis, clubbing, pedal edema,
lymphadenopathy.
• Height – 146 cm; Weight - 58 kgs; BMI - 27 kg/m2
• Height neck ratio -13
• No low posterior hair line.
• No neurocutaneous markers.
• No external markers of TB.
• No peripheral nerve thickening.
• Pulse rate – 88/min, regular rhythm, Normal volume & character, felt in all
peripheral vessels, no radio-radial or radio-femoral delay, no vessel wall
thickening .Carotid artery - No bruit.
• BP - 120/70 mmHg in right arm sitting position
110/70 mmHg in left arm sitting position.
• RR - 14/min, regular rhythm ,abdomino thoracic type.
• Spo2 - 98% in RA
• Temperature - 98.6 °F
• Conscious & co-operative.
• Oriented to time, place & person.
• Memory – immediate, recent & remote - intact.
• Language –
spontaneous/comprehension/fluency/repetition/naming/ –normal
• speech-Lingual dysarthria
• MMSE - 19/19
LINGUAL DYSARTHRIA
 CRANIAL NERVE
EXAMINATION
Test Right Left
OLFACTORY
NERVE Coffee + +
Asafoetida + +

OPTIC NERVE Test Right Left

Visual acuity-
Snellen chart Perception of 6/60
hand movements

Field of vision- Normal Normal

Confrontation
test

Colour vision- Normal Normal

Ishihara chart

Fundus Normal Normal

 CRANIAL NERVE - III/ IV / VI
Test Right Left
Ptosis No No
Extraocular Normal Normal
movements
Pursuit broken broken
Saccades Normal Normal
Nystagmus No nystagmus No nystagmus

Pupil Pupil size 2mm D shaped pupil

Direct Light Present Absent
Reflex
Indirect light Present absent
reflex
Accomodation Normal Normal
Reflex
• No Nystagmus
• EOM -Full
 TRIGEMINAL NERVE
Right Left
Muscles of No wasting, able to No wasting, able to
mastication chew chew
Sensory Normal Normal
(touch, pain &
temperature)

Right Left

Corneal reflex Present Present

Conjuntival reflex Present Present

Jaw jerk Absent

 FACIAL NERVE - Motor
• Wrinkling over forehead - symmetrical

• Able to close eyes tight against resistance in both sides

• Nasolabial fold is mild asymmetrical on left side

• No deviation of angle of mouth

• Patient is not able to blow the cheek & whistle

 FACIAL NERVE - Sensory

Test Right Left

Taste sensation over Normal Normal

anterior 2/3 of
tongue
 VESTIBULOCOCHLEAR NERVE
Right Left

Rinne's test AC > BC AC > BC

Weber No lateralisation

Vestibular No nystagmus
No swaying
GLOSSOPHARYGEAL AND VAGUS NERVE
Test Right Left

Symmetry of Normal Normal

palatal arch & its
movement

Gag reflex Normal Normal

SPINAL ACCESSORY NERVE

Test Right Left

Shrugging of shoulders Normal Normal

against resistance

Turning of head sideways Normal Normal

against resistance
 HYPOGLOSSAL NERVE

Wasting, Fibrillations Absent

Protrusion of tongue Deviated to left side

Able to press against the buccal aspect of Decreased on right side

cheek

Movement of tongue side to side Difficulty to move towards Right side

Tone Normal
SPINOMOTOR EXAMINATION
ATTITUDE:
• Patient in supine position
• B/L UL on the side of the body.
• B/L LL extended at the knee and hip joint, in supine position
 BULK
Right Left

Arm 24 cm 24 cm

Forearm 20 cm 20 cm

Thigh 44 cm 44 cm

Leg 28 cm 28 cm
 TONE

RIGHT LEFT

Upper limb Normal Normal

Lower limb Normal Normal

 POWER - UPPER LIMB

SHOULDER Right Left

Flexion 4-/5 4+/5

Extension 4-/5 4+/5

Abduction 4-/5 4+/5

Adduction 4-/5 4+/5

ELBOW Right Left

Flexion 4-/5 4+/5

Extension 4-/5 4+/5

WRIST Right Left

Palmar Flexion 4-/5 4+/5

Dorsi flexion 4-/5 4+/5

 POWER - LOWER LIMB

HIP Right Left

Flexion 4-/5 4+/5

Extension 3/5 4/5

Abduction 4-/5 4+/5

Adduction 4-/5 4+/5

Knee Right Left

Flexion 4-/5 4+/5

Extension 4-/5 4+/5

Ankle Right Left

Dorsiflexion 4-/5 4+/5

Plantar flexion 4-/5 4+/5

 REFLEXES
SUPERFICIAL REFELEXES Right Left

Corneal present present

Conjunctival present Present

Abdominal Present Present

Plantar Extensor Extensor

DEEP TENDON Right Left
REFLEXES
Biceps 2+ 1+

Triceps 2+ 1+

Supinator 2+ 1+

Knee 2+ 1+

Ankle 1+ 1+
 SENSORY SYSTEM

Pain Impaired on Right half of

body
Temperature

Crude touch Impaired on Right half of body

Pressure
Vibration sense Impaired on Right half of the body

Joint position sense Normal

Romberg's test -NEGATIVE

 CORTICAL SENSATIONS
CHEKED IN UPPER LIMB

CORTICAL SENSATION Right Left

Tactile localization Normal Normal

Two point discrimination Normal Normal

Stereognosis Normal Normal

Graphesthesia Normal Normal

 CEREBELLUM

COORDINATION Right Left

UPPER LIMB

Finger nose test Normal Normal

Finger-finger nose Normal Normal

test

Dysdiadochokinesia Normal Normal

LOWER LIMB

Heel shin test Normal Normal

GAIT Circumduction

• No nystagmus

• No intentional tremors

• No scanning / staccato speech

• No titubation / rebound phenomenon

 AUTONOMIC NERVOUS SYSTEM:

• No postural hypotension
• No resting tachycardia
• No trophic changes, abnormal sweating or flushing

EXTRAPYRADIMAL SYSTEM:

• No resting tremors
• No bradykinesia
• No rigidity
SIGNS OF MENINGEAL IRRITATION:
• No neck stiffness
• Kernig’s sign - negative
• Brudzinski’s sign - negative

EXAMINATION OF SPINE AND CRANIUM:

• No scoliosis/kyphosis
• Cranium - Normal
 OTHER SYSTEM EXAMINATION

• CVS: S1& S2 heard; no murmurs.

• RS: B/L Vesicular breath sounds heard; no added sounds.

• ABDOMEN: Soft, non tender

no free fluid
no organomegaly.
 DIAGNOSIS
STRUCTURES INVOLVED:
Left corticospinal tract
Left spinothalamic tract
left dorsal column
Left LMN 7th nerve palsy
Left LMN 12th nerve palsy
ANATOMICAL LEVEL:
Left Medulla

PATHOLOGICAL DIAGNOSIS:
Acute cerebrovascular Accident .,probably thrombotic in origin
ETIOLOGICAL DIAGNOSIS: probably
[Link] Mellitus
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