Approach To Evaluation of CNS Cases

Approach to Evaluation of CNS Cases (Examples)
EXAMPLE 1 (S TROKE)
A 70 YEAR MALE PRESENTED WITH COMPLAINS OF WEAKNESS OF RIGHT SIDE OF BODY AND
FACE FOR 1 DAY. HOW DO YOU APPROACH TO EVALUATE THE CASE?
My provisional diagnosis is LEFT SIDED STROKE. I would evaluate the case in following order:
A. INFORMED CONSENT
B. PARTICULARS INCLUDING HANDEDNESS OF THE PATIENT
C. HISTORY
I. Presenting complain: Hemiparesis with hemi-sensory loss with
facial weakness on same side
Embolic stroke occur suddenly with maximal
II. Elaboration of chief complains (Weakness in this case): neurological deficits at onset
– Course of illness: precise time of appearance and rate of
progression of symptoms Thrombotic stroke occur suddenly and may
progress in a stepwise fashion
– Distribution: limbs, face
– Severity
– Comparison of severity of weakness in affected sites
– Any significant preceding factors
III. Associated symptoms:
– Sensory loss: distribution and type
– Speech: affected in lesions of dominant hemisphere
– Swallowing
– Gait changes
– Bowel/bladder incontinence or retention
– Consciousness level Headache, vomiting, altered consciousness, seizures and marked HTN
– Headache, vomiting are common in hemorrhagic stroke than ischemic stroke.
– Seizures May be seen in ischemic stroke if associated with raised ICP.
– Visual field defects, diplopia - Ipsilateral cranial nerve and cerebellar involvement in posterior
– Facial deviation
circulation stroke.
– Vertigo, dizziness
- Contralateral lower facial nerve paralysis and homonymous
– Ataxia
hemianopia seen stroke of MCA territory
– Fever
– Trauma
IV. Assessment of risk factors:

– Similar history in past: TIA
– HTN, Diabetes, Dyslipidemia
– Peripheral vascular disease (limb pain, claudication, discolouration) Risk factors for stroke
– Cardiac illness
– Drugs: Aspirin, Warfarin
– Smoking, Alcohol 1
– Epilepsy, Migraine May mimic stroke
– Significant family history

| Dr K C
D. EXAMINATION
I. General Physical Examination
Level of consciousness: GCS scale
Posture: decorticate position in stroke
Built: Obesity is a risk factor for stroke
Pulse: Atrial fibrillation (irregular pulse) may be a source of emboli

Hypovolemic pulse suggest dehydration which needs correction
Weak/absent peripheral pulse in peripheral artery disease
Carotid bruit in carotid stenosis due to atheroma
Rigid wall of arteries in arterioselerosis due to HTN
BP: Adequate BP required to maintain cerebral perfusion pressure
Temp: Hyperthermia increases cerebral metabolism hence needs to be corrected
II. Neurological examination:

Level of consciousness - Altered in ischemia of cerebral cortex but not in lacunar infarcts
Higher mental status - Progressive deterioration if raised ICP
Features of meningism
Speech: aphasia if dominant hemisphere is involved
Swallowing
Cranial nerves examination
Motor examination:
– Contralateral hemiparesis with features of UMN lesion in stroke
– Hemiplegic gait may be present
Sensory examination:
– Hemi-sensory loss in same side of weakness
Cerebellar examination
III. Cardiovascular examination:
Murmur, arrhythmias
E. INVESTIGATIONS in a case of stroke:

Investigation Significance
To identify ischemic Vs hemorrhagic stroke
CT/MRI scan (CT scan is faster, more commonly available and
relatively cost effective; hence preferred)
ECG, Echocardiogram To assess cardiac source of embolism
Duplex USG of carotids To assess underlying site of vessel involvement
CT/MRI angiography
CBC, Blood glucose, Cholesterol To assess risk factors 2
PT/INR, BT, CT If bleeding/clotting disorder is suspected
| Dr K C
EXAMPLE 2 (MENINGITIS)
A PATIENT PRESENTED WITH FEVER , HEADACHE AND ALTERED CONSCIOUSNESS FOR 3 DAYS.
WHAT IS YOUR PROVISIONAL DIAGNOSIS? HOW WOULD YOU EVALUATE THIS CASE?
My provisional diagnosis is ACUTE MENINGITIS. I would approach the case in following order:
A. INFORMED CONSENT
B. PARTICULARS OF THE PATIENT
C. HISTORY
Presenting complains: fever, headache, altered consciousness, neck stiffness
Elaboration of presenting complains:
– Fever: usually acute onset, high grade, continuous associated with chills and rigors
– Headache: acute onset, diffuse, continuous
– Excessive drowsiness
Features of meningism: neck stiffness, photophobia
Features of raised ICP: progressive headache, projectile vomiting, deteriorating consciousness
Features of complications:
– Seizures
– Focal neurological signs
Assessment of risk factors:

– Preceding illness: pneumonia, sinusitis, otitis
– Immuno-compromised state: DM, immunosuppressant, corticosteroids, splenectomy, HIV
– Head injury
– Head and ENT surgery
– TB
To rule out other causes of fever

Cough, chest pain, SOB
Urinary complains, loin pain
Diarrhea
| Dr K C
D. EXAMINATION
I. General Physical Examination:
– Usually lethargic and confused
– Decreased alertness: expressed in GCS scale
– Pulse: Tachycardia
Bradycardia in Cushing’s triad
– BP: Low BP if patient is in septic shock
High BP in Cushing’s triad
– RR: irregular breathing in Cushing’s triad
– Temp: usually high grade fever
Hypothermia if patient is in septic shock
– Dehydration may be present
– Rash present in meningococcal meningitis, DIC, viral infection
II. Neurological Examination:

– Kernig’s and Brudzinski signs: signs of meningism
– Pupils: dilated pupil in case of uncal herniation
– Cranial and motor examination: to assess focal neurological deficits
III. Other Systemic examinations:

Sinusitis, otitis, pneumonia
E. INVESTIGATIONS
CBC: leukocytosis with neutrophilia in bacterial meningitis
Normal / leukocytosis with lymphocyte predominance in viral meningitis
Thrombocytopenia in septic shock
RFT/RBS/Electrolytes: routine assessment of fluid and electrolyte
Blood Culture and sensitivity: to isolate bacteria and determine antibiotic sensitivity
Fundoscopy: to assess papilledema
CT Scan: to rule out brain abscess, sinus thrombophlebitis, tumor, empyema
Lumbar puncture: to diagnose bacterial / viral / tubercular/ fungal cause of meningitis
| Dr K C

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Approach to Evaluation of CNS Cases (Examples)

B. PARTICULARS INCLUDING HANDEDNESS OF THE PATIENT

IV. Assessment of risk factors:

– Epilepsy, Migraine May mimic stroke

– Significant family history

Pulse: Atrial fibrillation (irregular pulse) may be a source of emboli

II. Neurological examination:

E. INVESTIGATIONS in a case of stroke:

B. PARTICULARS OF THE PATIENT

Assessment of risk factors:

To rule out other causes of fever

II. Neurological Examination:

III. Other Systemic examinations:

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