OUTLINE OF THE SESSION

• How to take a proper history in a case of Hemiplegia

• Step by step symptom analysis ; How a clinician thinks

• Checklist for history taking that should at your finger tip

• Making a provisional diagnosis from history

• Mr. Vinod, 68 year old male hailing from Trivandrum, Kerala

Previously was an Engineer

DOA : 20th March 2023

DOE : 21st March 2023

Informant : Patient and his wife

PRESENTING COMPLAINTS
• Weakness of right upper and lower limb - 1 day

Slurring of speech - 1 day

ANALYSIS
 HISTORY OF PRESENT ILLNESS
• Patient was apparently normal until 6am in the morning

when he woke up from sleep. Five minutes later, after

brushing his teeth, while he was walking to the toilet, he felt that

his right lower limb was getting weak. He felt heaviness and

dragging of his right lower limb. He was however able to walk of

his own, though with slight difficulty.

ANALYSIS
Lower Motor Neuron Lesion
PYRAMIDAL DISTRIBUTION OF WEAKNESS
EXTRAPYRAMIDAL TRACT
BASAL GANGLIA
EXTRAPYRAMIDAL TRACT
• Extrapyramidal upper motor neuron system

• Bulbospinal upper motor neuron system

Functions of Extrapyramidal pathways
Extrapyramidal pathways
• Tectospinal pathway
• Vestibulospinal pathway
• Reticulospinal pathway

• Rubrospinal pathway
 HISTORY OF PRESENT ILLNESS
• In the span of next 2 hours, he noticed dropping of objects
from the right hand and difficulty in raising right upper limb.

• Another 2 hours later, while attempting to walk, he fell down

and noticed that he was not able to walk of his own and
required the assistance of 2 persons. Also since then, he was
not able to move his right upper limb.
ANALYSIS
 HISTORY OF PRESENT ILLNESS

• At that time, his wife noticed that there was deviation of angle of his
mouth to the left. There was drooling of saliva from right corner of

his mouth. There was no difficulty in eye closure.

ANALYSIS
 HISTORY OF PRESENT ILLNESS
• Wife then noticed that his speech became slurred and was not as
legible as before . No reduction of word output during conversation.

However, he was obeying all commands told to him.

ANALYSIS
• APHASIA

• DYSARTHRIA
TYPES OF DYSARTHRIA
• Spastic/UMN
• Flaccid/LMN
• Cerebellar
• Hyperkinetic
• Hypokinetic
• Mixed
 HISTORY OF PRESENT ILLNESS
• No sensory symptoms.

• No history suggestive of other cranial nerve involvement .

• No headache, vomiting, seizures.

• No vertigo.

• No bladder symptoms .

• No chest pain, palpitations.

• No loss of consciousness or impairment in consciousness.

 HISTORY OF PRESENT ILLNESS
• No fever, night sweats, weight loss.

• No cough, hemoptysis.

• No breathlessness.

• No bed sores.

• The patient was brought to the hospital within 9 hours of onset of symptoms.

• No further progression/improvement of disability over past 1 day.

Checklist of symptoms in a Hemiplegia case
• Motor
• Sensory
• Speech
• Cranial nerves
• Bladder
• Cerebellar
• Vestibular
• Features of raised ICT
• Cardiac symptoms, Respiratory symptoms
• Fever - either new onset or prolonged fever
• Any complications - Aspiration pneumonia, UTI, Bed sores
• Rule out stroke mimics
 HISTORY OF PAST ILLNESS
• He has type 2 diabetes for past 12 years and is on insulin

• Most of the recent blood sugar values are above 250 mg%

• He has systemic hypertension for 10 years and is on medications.

• No history suggestive of coronary artery disease, thyroid disease, bronchial asthma.

• No previous surgeries.
DRUG HISTORY
• He is on the following medications
Inj Human Mixtard (30/70) 28-0-24 u s.c
Tab Amlodipine 5mg 1-0-1

• Poor drug compliance

• No history of drug allergies

PERSONAL HISTORY
• Not a smoker, not an alcoholic.

• He consumes a mixed diet, which is poor is fruits and vegetables.

• Bowel and bladder habits regular.

• No history of illicit drug abuse.

• No high risk sexual behaviour.

 FAMILY HISTORY
• History of type 2 diabetes in father, mother, brother and maternal uncle.

• His father died due to stroke related complications at 60 years of age

• His mother had a history of Myocardial Infarction

OCCUPATIONAL HISTORY
• Pensioneer

• Monthly income : around Rs 10,000

• Average socioeconomic status

CASE SUMMARY
DIAGNOSIS
FUNCTIONAL DEFICIT
ANATOMICAL SITE
ETIOLOGY
CO-MORBIDITIES
PROVISONAL DIAGNOSIS
YOUNG S TROKE
 GENERAL EXAMINATION
• Conscious, oriented in time, place & person. Co-operative for examination

• Moderately built & nourished

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

• PR - 76/min, regular. Other peripheral pulses felt equal bilaterally

• BP - 170/90 mm Hg in Right upper limb in supine position
• RR - 16/min
• Temperature - 98.7 deg F

• No significant head to foot examination finding

EXAMINATION OF NERVOUS SYSTEM
 HIGHER MENTAL FUNCTION
Btech degree holder. Retired Engineer. Right handed. Knows Malayalam, English & Hindi.
• Alert
• Oriented in time, place and person
• Attentive
• Immediate, Recent & Remote memory – Normal

• Speech
Fluency- Increased effort with syllables running into one another. Reduced word output.
Comprehension, Repetition, Naming & word finding, Reading – Normal
Writing could not be tested
Impression – Spastic Dysarthria

• Normal Intelligence
• Appearance : Well dressed. Co-operative
• Mood – Normal. No delusions, hallucinations or illusions
EXAMINATION OF THE CRANIAL NERVES

• Optic nerve - Right homonymous hemianopia

• Facial nerve - Deviation of angle of mouth to left side on

attempted speaking or smiling
Loss of nasolabial fold on right side
Platysma - weak on the right side
Forehead wrinkling – Normal on both sides
No involuntary movements
Taste sensation in anterior two-third of tongue - Normal
 GENERAL EXAMINATION
• Conscious, oriented in time, place & person. Co-operative for examination

• Moderately built & nourished

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

• PR - 76/min, regular. Other peripheral pulses felt equal bilaterally

• BP - 170/90 mm Hg in Right upper limb in supine position
• RR - 16/min
• Temperature - 98.7 deg F

• No significant head to foot examination finding

EXAMINATION OF NERVOUS SYSTEM
HIGHER MENTAL FUNCTION
 LEVEL OF CONSCIOUSNESS
• Alert
• Confusion
• Delirious
• Lethargic/Drowsy
• Obtunded
• Stupor
• Coma
Altered sensorium + Hemiparesis
ORIENTATION
• Time

• Place

• Person
Disorientation in Stroke
ATTENTION
• Is he attentive to questions ?

• Can he engage in a continuous conversation ?

• Serially subtract 3/5/7 from 100

 MEMORY
• Immediate memory

• Recent memory

• Remote memory
Stroke with impaired memory
 SPEECH

Is the patient having normal speech, dysarthria, aphasia, dysphonia

Fluency
Comprehension
Repetition
Naming & word finding
Reading
Writing
Language in Stroke
INTELLIGENCE
APPEARANCE & BEHAVIOR
MOOD
 HIGHER MENTAL FUNCTION

• Educational status • Level of consciousness

• Occupation • Orientation
• Handedness • Attention
• Knowledge of languages • Memory
• Speech
• Intelligence
• Appearance & behavior
• Mood, delusions & hallucinations
 HIGHER MENTAL FUNCTION
Btech degree holder. Retired Engineer. Right handed. Knows Malayalam, English & Hindi.
• Alert
• Oriented in time, place and person
• Attentive
• Immediate, Recent & Remote memory – Normal

• Speech
Fluency- Increased effort with syllables running into one another. Reduced word output.
Comprehension, Repetition, Naming & word finding, Reading – Normal
Writing could not be tested
Impression – Spastic Dysarthria

• Normal Intelligence
• Appearance : Well dressed. Co-operative
• Mood – Normal. No delusions, hallucinations or illusions
EXAMINATION OF THE CRANIAL NERVES

• Optic nerve – Right homonymous hemianopia

• Facial nerve – Deviation of angle of mouth to left side on attempted

speaking or smiling
Loss of nasolabial fold on right side
Platysma – weak on the right side
Forehead wrinkling – Normal on both sides
No involuntary movements
Taste sensation in anterior two-third of tongue - Normal
Cranial Nerve Examination
Olfactory nerve
Optic nerve
Visual Acuity
• Distant vision

• Near vision

• Improvement of Visual acuity on pinhole test

Visual Field
• Confrontation method

• Menace reflex
Color Vision
• Ishihara chart
Optic Fundus
OPTIC DISC
PALE OPTIC DISC (Optic Atrophy)
• Cup : normal depression within center of disc

• Cup is paler than the disc

• Cup disc ratio

• Deep cup

• Elevated cup
Hypertensive Retinopathy
Examination of III, IV,VI th cranialnerves
• Eyelids
• Extra-ocular movements
• Pupil
• Nystagmus

• Saccades
• Pursuit
EyeLids &Eyeballs
• Lid retraction
• Ptosis
• Proptosis

• Squint
Extra-ocularmovements
Pupil
• Size
• Shape
• Equality
• Regularity
• Light reflex - Direct & Consensual
• Accommodation reflex
DirectReflex
• Bright beam of light shown suddenly from sides

• Afferent 2nd nerve, centre midbrain, efferent 3rd nerve

Consensual reflex
• Assistant - Background illumination
Lighted torch from below. Allow time for pupil to adapt

• Card kept between two eyes

• Light shown to one eye

• Look for pupillary constriction in other eye

Accommodation Reflex
• Finger 22 cm in front and at the level of nasion

• Look at a distance

• Quickly look at tip of finger

• Look for pupillary constriction

 Nystagmus
• Patient asked to look straight

• Is there any nystagmus in primary position ?

• Patient asked to hold the gaze at 45 degree (on either degree)

• Look for nystagmus

 Examination of Vth nerve
• Motor : Temporalis, Masseter, Pterygoids

• Sensory : Ophthalmic, Maxillary, Mandibular

• Reflexes : Corneal, Conjunctival, Jaw jerk

 Examination of VIIth nerve
• Is facial palsy present or not ?

• If present, unilateral or bilateral ?

• UMN or LMN ?
 Examination of VIII th nerve
• Cochlear part • Vestibular part

Rinne test Nystagmus

Weber test

Absolute bone conduction test

 Examination of IX & Xth nerve
• Pitch & quality of patient’s voice

• Position of uvula

• Movements of the palate

• Gag reflex

• Palatal reflex
 Examination of IX & Xth nerve
• Afferent of gag reflex – 9th nerve

• Efferent – 10th nerve

• Gag reflex decreased or absent in LMN lesions

• Gag reflex is exaggerated in UMN lesions

 Examination of XIth nerve
• Left hemisphere controls head turn to the right (left sternocleidomastoid)

• Right hemisphere controls head turn to the left (right sternomastoid)

• Left hemispheric stroke - Right hemiplegia - Left sternomastoid weak

 Examination of XII nerve
• Inspection
Inside the mouth : Any wasting, fasciculations. Deviation ?
Protrude the tongue : Look for deviation

• Power of tongue muscles : Push against cheek

• Palpate the tongue : Tone ?

 Examination of XIIth nerve
• UMN Lesion

Inside the mouth – Midline

Protruding the tongue – Tongue deviates to affected side

• LMN lesion

Inside the mouth – Deviate to the normal side

Protruding the tongue – Tongue deviates to affected side

 INTRINSIC EXTRINSIC
• Longitudinal • Genioglossus

• Transverse • Geniohyoid

• Vertical • Hyoglossus

• Styloglossus
 Examination of XII nerve
• Longitudinal intrinsic muscles
On each side retract the tongue backwards & ipsilaterally

• Genioglossus
Protrudes and pushes the tongue to the other side
 Examination of XII nerve
• Unilateral LMN 12th nerve palsy
Inside the mouth – Deviated to the contralateral (normal) side

Protruding the tongue – Tongue deviates to ipsilateral (affected) side

 Rule of 17
• Lesions of cranial nerve 12 & 5 – Deviation to paralyzed side

Lesions of cranial nerve 10 & 7 – Deviation to healthy side

 EXAMINATION OF MOTOR SYSTEM

• Bulk
• Tone
• Power
Reflexes
 REFLEXES
• Superficial reflexes

• Deep Tendon Reflexes

• Release reflexes/Primitive reflexes

 Superficial Reflexes
• Corneal

• Conjunctival

• Gag/Palatal reflex

• Abdominal reflex

• Cremasteric reflex

Plantar reflex

Bulbocavernous reflex
 Deep Tendon Reflexes
• Jaw jerk • Finger flexion

Trapezius jerk Pectoral reflex

Biceps jerk Deep abdominal reflex

Supinator jerk Knee jerk

Triceps jerk Ankle jerk

 Grading of Deep Tendon Reflexes
• 0 - No contraction even on re-inforcement

1+ - Present but diminished

2+ - Normal

3+ - Exaggerated

4+ - Exaggerated with clonus

 Release Reflexes
• Extrapyramidal system affection

Bilateral corticobulbar affection

 T E S T S F O R CO-ORDINATION
• Upper limb co-ordination • Lower Limb co-ordination

Finger – nose test Heel Knee test

Finger to finger nose test
• Toe finger test
Rebound phenomenon

Past pointing

Dysdiadochokinesia
 P O S S IB L E S ITE S O F L E S IO N

- Cerebellum or its connections

- Large fibers of peripheral nerves
- Dorsal root ganglion
- Posterior column
- Frontal lobe and its connections
- Vestibular system
 TITUBATION
• Nodding of the head

• Anteroposterior

Side-side

• Inability to hold head and neck steady and upright

TRUNCAL ATAXIA
 GAIT ATAXIA
• Has to be inspected for swaying

while standing : Volitional posture

while walking : Volitional foot placement

• Broad based stance

Broad based gait

•Reeling

•Drunken

•Ataxic
How to overcome this compensation ?
Vermis lesions
• Titubation

• Truncal ataxia

• Tandem gait impairment

GAIT ATAXIA + VERTIGO + VOMITING
LIMB ATAXIA
• Appendicular ataxia

• Difficulty in carrying out tasks requiring precision

- buttoning and unbuttoning of shirt

- taking glass of water to the mouth

- opening cap of a bottle

 SPEECH
• Dysarthria

• Inco-ordination of laryngeal, lingual & palatal muscles

• Slow, slurred & irregular

• Staccato
Scanning
HYPOTONIA
• Gamma motor neuron

• Reflexes - preserved
PENDULAR KNEE JERK
PENDULAR KNEE JERK
• Hypotonia of the knee flexors & extensors

Normally functioning reflex arc

 DYSMETRIA
• Inability to arrest the movement at a desired point

Tested by Finger nose or Finger nose finger test

Error of judgement in distance, direction, range & speed of movements

• Hypermetria/Overshoot/Past pointing

• Hypometria
DYSSYNERGIA
• Decomposition of complex movements

Broken down to mall jerky & clumpsy movements

• Increase in reaction time

• Tested by heel-knee test

DYSDIADOCHOKINESIA
• Inability to perform rapid alternating movements

Performed by rapid hand supination & pronation test

 REBOUND PHENOMENON
• Check reflex/Holmes phenomenon

Tested by asking patient to flex elbow against resistance

• Failure of antagonist muscle group to counter overshoot

INTENTION TREMORS
• - towards the end of precise movements (at the goal point)

- best appreciated while performing finger-nose finger test

NYSTAGMUS
 CHECK LIST FOR CLINICAL APPROACH
• History
- Age
- Is it true ataxia or ataxia mimic ?
- How is the onset and progression ?

Acute (minutes to few days)

Subacute (weeks to months)

Chronic (months to years)

ACUTE
SUB-ACUTE
CHRONIC
- Is it a pure ataxic syndrome or Ataxia +
Parkinsonism – MSA-c

Dementia - CJD
Myoclonus - CJD

Vision problems and ocular motor disturbances

– MFS, MS, Vit B12 def, Wernicke’s
Peripheral neuropathy – FA
 Fever – Infectious cerebellitis

GI symptoms – Whipple’s , Abetalipoproteinemia

Constitutional symptoms - Paraneoplastic

Multisystem - Mitochondrial

Focused approach can help narrow differentials

• Is there any drug history ?
- Alcohol
- Phenytoin
- Lithium
- Anticancer drugs (5-FU, cytosine arabinoside)

• Is there history of heavy metal exposure ? (Lead, mercury, bismuth)

• History of high risk sexual behavior ?

• History of thyroid dysfunction ?

• History of jaundice
• Is there any family history
- Draw the family tree (ideally 3 generations are a must)
- Pattern of
inheritance
Autosomal dominant
Autosomal recessive
X-linked
Mitochondrial
 EXAMINATION
• Focused head to foot examination based on available information

- Telangiectasia

- Pes cavus

- KF ring

- Neck length ratio

- Short 4th metatarsal

 NEUROLOGICAL EXAMINAITON
• Speech

• Eyes

• Limbs

• Gait

Don’t disregard rest of examination (especially Ataxia+)

INVOLUNTARY MOVEMENTS
EXAMINATION OF GAIT
EXAMINATION OF SENSORY SYSTEM

• Superficial sensations • Deep sensations

Pain Sense of position

• Light touch • Sense of passive movement

Vibration
• Temperature
Pressure
EXAMINATION OF SENSORY SYSTEM

• Cortical sensations •

Tactile localization

• Two point discrimination

Stereognosis

Graphesthesia

Double simultaneous stimulation

• Hemisensory loss

• Hemisensory loss + Sensory loss over face

• Cortical sensory loss

EXAMINATION OF AUTONOMOUS NERVOUS SYSTEM
SIGNS OF MENINGEAL IRRITATION
EXAMINATION OF PERIPHERAL NERVE
EXAMINATION OF SKULL & SPINE
Rule of 4 – Brainstem Localization
Examination of other systems
• Cardiovascular system

• Respiratory system
Cardiovascular System
Respiratory System
EXAMINATION OF MOTOR SYSTEM

• Bulk – Normal on inspection and palpation

• Tone - Hypertonia of Right upper & lower limb

 Right Left
Shoulder Flexion 2 5
Extension 0 5
Adduction 2 5
Abduction 0 5
Elbow Flexion 2 5
Extension 0 5
Wrist Flexion 2 5
Extension 0 5
Hand grip Weak Normal
 Right Left
Hip Flexion 0 5
Extension 2 5
Adduction 0 5
Abduction 2 5
Knee Flexion 0 5
Extension 2 5
Ankle Dorsiflexion 0 5
Plantarflexion 2 5
• Plantar – Right extensor, Left flexor

• Abdominal reflex & Cremasteric reflex –Absent in Right side

• Deep Tendon reflexes – Exaggerated on Right side compared to left

• Gait & co-ordination – could not be tested

• Sensory system – Decreased pain, temperature, touch and vibration in

right upper and lower limbs. Facial sensations - normal
Examination of Autonomic system – normal
No signs of meningeal irritation
Examination of peripheral nervous system - normal
Examination of skull & spine - normal
EXAMINATION OF OTHER SYSTEMS

• Normal
 FINAL CASE SUMMARY
• 68year old male with a long standing history of type 2diabetes & systemic
hypertension with poor drug compliance and a strong family history of vascular
co-morbidities, now presents with an acute onset neurological illness of 1day
duration which started as an acute onset mild weakness of right lower limb
progressing to severe functional disability of right hemiplegia over 4hours. He also
developed deviation of angle of mouth to left and slurring of speech. No history
suggestive of embolic etiology. No features of raised ICT. No other complications.
The patient reached the hospital within 9 hours of onset of symptoms. On
examination, he was conscious, oriented and co-operative for examination. Blood
pressure was elevated. Neurological examination showed Spastic dysarthria, Right
homonymous hemianopia, Right UMN Facial palsy, Right sided UMN Spastic
hemiparesis, Right hemisensory loss. Other systems were within normal limits
 DIAGNOSIS
• Acute onset Right hemiplegia
Right hemisensory loss
Right homonymous hemianopia
Right UMNFacial palsy
UMN Dysarthria
• Left Internal Capsule lesion
• Acute Ischemic Stroke possibly thrombotic in origin affecting
lenticulostriate branch of left Middle cerebral artery
• Poorly controlled Type 2Diabetes Mellitus
• Systemic Hypertension