Psa prostate

CNS BLOCKS

Headache
dizziness
difficulty in speaking
difficulty in hearing
difficulty in swallowing
memory loss
gait
weakness
loss of sensation
loss control of urine and stool
loss of consciousness
tremors

CNS EXAMINATION
Cranial Nerves

1) Olfactory nerves( It doesn’t exist in the exam)

2) Optic nerves (Cr2)
a) Visual acuity and color vision: if there is small chart in the room then take
the chart and stand 14 inches or 30cm from the patient and ask about the
last line which the patient can read and also ask about color identification
at the bottom of visual acuity page.
b) Field of vision: Ask the patient to cover his right eye first then you cover
your left eye and check for field of vision and check the opposite side and
say normal field of vision.
c) Opthalmoscopy: Say I need to do opthalmoscopy.
3) Occulomotor , trochlear and abducent nerve Cr 3,4,6:
comment on pupils and say pupil is normal in size, shape and symmetry, then put
light on pupils and say normal reaction to direct and indirect light reflex. Now ask
 the patient to follow your finger with his or her eye without moving the head and
make a big H and say normal extraocular movement and no nystagmus, normal
convergence
4) Trigeminal nerve Cr 5
a) Motor: for masseter and temporalis muscle ask the patient to clench his
teeth. For pterygoid put the finger under the chin and say can you open the
mouth and resist opening of the mouth.
b) Sensory: check for ophthalmic, maxillary and mandibular component.
5) Facial nerve Cr 7
comment on face no asymmetry of face and no mouth deviation.
a) Motor: ask the patient to raise the eyebrow, show his teeth , puff out your
cheek, close the eye and tell the patient to don’t let you open the eye.
b) Sensory: Say I need to check the taste sensation of the anterior 2/3 of
tongue.
6) Vestibulocochlear nerve: Cr 8
Tell the patient to repeat the words you say now. Now close the patient right ear
and whisper 1, 2, 3 in the left ear and ask the patient to repeat.now close the left
ear and whisper hospital in the right ear and ask the patient to repeat. If patient is
not able to repeat then ask for weber’s and rinne’s test.
7) Glossopharyngeal nerve: Cr 9
Can you open your mouth and say “ah” and then comment that there is no
deviation of uvula. Say I need to do taste sensation on the posterior 1/3 of the
tongue.
8) Vagus Nerve: Cr 10
Pt is speaking indicating vagus nerve is intact.
9) Accessory nerve:Cr 11
Check for sternocleidomastoid and trapezius muscle and say accessory nerve
intact.
10) Hypoglossal nerve:Cr 12
Say show me your tongue and say there is no tongue deviation. If the lesion is on
the left the tongue will deviate to the same side.
 11) Motor as usual.
12) Sensory examination as usual.
13) Reflex as usual.
14) Gait
a) wide based gait= cerebellar ataxia
b) high stepping gait= L5
c) short shuffling gait= parkinsonism
d) hemiplegic gait= stroke

Headache (adult or kids or women)

1) OCD+ Pain
2) D/D
a) Any fever+ neck stiffness( meningitis)
b) Did you passed out , any weakness, loss of sensation(stroke)
c) Any eye pain or eye discharge(glaucoma)
d) Any ear pain or ear discharge(AOM)
e) Runny nose or face pain ( sinusitis)
f) Pain in chewing with problem in vision( Giant cell arteritis)
g) Flashes, blurring of vision, abnormal movement before headache( migraine)
h) Nausea , vomiting, nipple discharge( pituatory tumor)
i) Heart racing and sweating( pheochromocytoma)
j) Nausea, vomiting and early morning headache( raise ICP e.g: tumor or SAH)
k) Trauma
l) Medication
m) Any stress in your life
n) How’s your mood
 Physical examination of Headache

1) 4 steps.
2) CN( 2,3,4,6 and 7)
3) Motor
4) Sensory
5) Reflex
6) Gait
7) Sign of Meningitis; kerning’s, brudzinki’s. Neck rigidity and scratch marks on
hand

Kernig’s: pain in the neck on extension of the knee with the hip in 90 degrees of flexion.
Brudzinski’s: pain on passive flexion of the neck causes flexion of the hips and knees

8) Sign of infection: eye , ear and say I need to do otoscopy, press on the cheek
for sinusitis, lymph node , throat, listen to chest and heart)

Investigation

1) CT Head: can be 3 possibility: normal do lumbar puncture, tumor diagnose

with CT , If SAB then do CT angiography)

75 yr Sara Anderson .She had headache and difficulty of

vision

1) OCD+ pain( you will find patient have pain on chewing )

2) D/D of headache.
3) Specific Qs: any pain in muscles ( polymyalgia rheumatica). Any chest pain . any
abdominal pain( mesenteric ischemia)
4) Neuro block
5) General Qs:
 Fx headache, brain tumors

Diagnosis: giant cell arteritis

Investigation:
1) ESR
2) CRP
3) Temporal artery biopsy( if biopsy I negative then do it again)

Medication:
Prednisone: 40-60 mg for 4 weeks then taper 5mg/wk until the dose is 10 mg then taper
1mg/day until complete .
For Polymyalgia rheumatica: 15mg for 2 weeks then taper 12.5mg for 2 weeks then
10mg for 4 weeks and then 1mg/day until complete

35yr old Jack Miller complains of headache and problem with

vision and he is hitting furniture and people during walking,
Take a focus history and do focus neurological exam

OCD + Pain
D/D of Headache
Specific qs: Nipple discharge, change in your feet size,does heat and cold bother you
more than other, how’s your sexual desire , How’s your menstruation for female.do you
drink more and pee more.
Neuro blocks Qs
General Qs

P.E or (Neurological exam)

 1) 4 steps
2) Cranial nerves 2,3,4,6 and 7 (field of vision)
3) Motor U/L
4) Sensory U/L
5) Reflex U/L
6) Gait
7) Meningeal signs (neck rigidity, kernign’s and brudzinki’s , skin scratch)
8) Sign of infection
9) Swelling of face, normal size of hand and feet.
10) Chest for gynecomastia and nipple discharge.
11) Abdomen: no striae and no hepatosplenomegaly.

35yr old .She needs to renew her prescription for fiorinol

(aspirin, barbitone,caffeine). She has been talking this
medication for last 2 years

I need a prescription for this pill

Why do you take the medication?
How long you are taking this medication?
Who prescribed for you?
Why did not you go to your doctor?
Name and location of your pharmacy?

OCD+ Pain
DD.headache
Specific Q: (Is this the same type of headache that before as usual), how is mood?
How does that affect your daily activity? Suicide/ homicide?

Neuro Blocks
General Qs
Fhx of migraine/brain tumor, drugs
Do you have the bottle with you? Red flag
Confirm the name
Confirm the date (you will find that she is taking medication more then usual dose or the
bottle is empty then say oh it is empty why you took all the medicine)

Diagnosis: Medication over use headache

Counseling:
I need to examine you and send for some investigation. This headache is not to same
headache like before. So continuing the same medicine will not help you .This is a
medicine over use headache. Without medication, this pain will disappear in couple of
days if not I would recommend you to come see me in order to look for other causes. I
will send you to be seen by psychiatrist. I advise you to avoid stress, good sleep Avoid
coffee). I encourage you to stop these medications as unfortunately I can not prescribe it
for you. If it would be difficult for you, I would refer you to rehab centers. I will see you
soon within few days to see what happened to you.
Do you have any questions?

Same scenario but patient is taking acetaminophen+ codeine

Pt will be taking Tylenol 3 and he is continuous demanding pills.

Why do you take the medication?
How long you are taking this medication?
Who prescribed for you?
Why did not you go to your doctor?
Name and location of your pharmacy?

1) OCD+ Pain
2) D/D of headache
3) Specific Q: Agitation, muscle pain, feels heart racing and diarrhea
(withdraual symptoms)
 how is mood?
How does that affect your daily activity? Suicide/ homicide?
4) Neuro Blocks
5) General Q
6) The Bottle as before

Counseling
I need to examine u and send for investigations, So I can understand now that these
symptoms are withdrawal symptoms. Continuing the medication will never help you, it
will make you more dependable on the medication. I will give you medication like
Tylenol that will help you. This pain will disappear in couple of days if not I would
recommend you to come see me in order to look for other causes. I will send you to be
seen by psychiatrist. I advise you to avoid drinking coffee before bedtime, don’t do
exercise before bedtime and don’t read before bed time and avoid stress)
I encourage you to stop these medications as unfortunately I can not prescribe it for you.
If it would be difficult for you, I would refer you to rehab centers. I will see you soon
within few days to see what happened to you.
Do you have any questions?

30yr old patient had unconsciousness at play ground, diabetic

and now he is in E.R drowsy and having headache. You are a
doctor in rural area do a focus history focused physical exam.

1) OCD+ Pain.( pt will mentioned that it is a worst headache of his life)

2) D/D of headache: nausea ,vomiting
3) Neuro blocks
4) General Qs.
 P/E: As usual

Case of Migraine in 14 years old: As usual

Migraine

Medical treatment of migraine headaches in children is based on the

following: (1) education of children and parents or caregivers about
migraine triggers, (2) creation of a plan of immediate treatment for the
attacks, and (3) consideration of preventive medicines or measures for
children with frequent migraines.
Education
The doctor should explain the disease to the child and the parents or
caregivers. The treatment of children with mild, infrequent migraine attacks
consists mainly of rest, trigger avoidance, and stress reduction.
The doctor should also assure parents that the headache is not caused by a
brain tumor or other life-threatening condition. A regular bedtime, strict
meal schedules, and not overloading the child with too many activities are
important. Helping the child recognize migraine triggers is helpful but often
difficult. Ridding migraine triggers reduces the frequency of headaches in
some children but does not completely stop occurrences.
A headache diary can be used to record triggers and features of attacks.
Triggering factors that occur up to 12 hours prior to an attack should be
noted. Other important factors to include are as follows:
Date and time the attack began
Type and location of headache pain
Symptoms before the headache
All food and drink consumed prior to the attack
Bedtime, wake time, and quality of sleep prior to the attack
Menstrual periods or female hormones (if applicable)
Activities before the headache began
Medications taken and their side effects
Unfortunately, even the most diligent person cannot always identify specific
migraine triggers.
Immediate treatment
At the time of attack, parents or caregivers should have the child lie down in
a cool, dark, quiet room to help him or her fall asleep. In spite of the
development of many effective anti-migraine medications, sleep is the most
powerful and best treatment. During a migrainous attack, a child can often
be found resting in the fetal position with the affected side of the head down.
Some children find that ice or pressure on the affected artery can reduce pain
for a short time. Nonsteroidal antiinflammatory drugs (NSAIDs) are
effective if taken at a high but appropriate dose during the aura or early
headache phase. Common over-the-counter (OTC) NSAIDs include
ibuprofen (Advil, Children's Advil/Motrin, etc.) and naproxen (Aleve,
Naprosyn, Anaprox, Naprelan). Acetaminophen (Tylenol and others) may
also be used for pain control. Aspirin should not be used in children or
adolescents.
Other treatment methods, such as self-relaxation, biofeedback, and self-
hypnosis, may be reasonable alternatives to drug therapies in childhood
migraine, particularly in adolescents.
Prevention and Therapy
The primary goals of preventive therapy are to prevent migraine attacks and
to reduce the frequency and severity of attacks. Most preventive migraine
medications have potential side effects, so only children with at least 1-2
attacks per week should take them. Parents and caregivers should have
realistic expectations. While medications lessen the impact of migraines,
they do not get resolve the underlying causes. Half of all patients experience
a 50% reduction in migraines (at most)

65yr old tremors in hand do a focus physical exam

1) 4 steps
2) Explain Parkinsonism patient

Look at the face and say mask face and loss of eye blinking.
Look at the hands and say resting pill rolling tremors.
3) Ask the patient to get up from the chair pt will slowly rise from the chair and
comment on bradykinesia
Ask the patient to walk and comment short shuffling gait and loss of arm swing
and tell the patient to turn and say patient turns in block and then suddenly pull
the patient back pt will be unstable and about to fall hold the patient and say to
him that it was a test and comment to the examiner about the postural instability
4) Shake patient hand and rotate hand and check for cogwheel rigidity
5) Speech: can you say “ British Constitution” no slurred speech
6) Eye: 2, 3,4, and 6th cranial nerves+ pupil and extra ocular movement for
nystagmus.
7) Cerebellar signs: finger nose test (comment no intention tremors and no past
pointing), heel shin test, dysdiadokinesia.
8) Motor as usual
9) Sensory as usual
10) Reflex
11) Ask patient to write a sentence for you and comment no micrographia.
12) Thyroid exam: if time
42 yr old Sara Anderson. She has numbness , tingling in the
left 3 fingers . Take a history and physical exam.

1) OCD ( What were you doing when it started , what make it worse (job)
secretatory
what make it better ?she shake her hand vigorously to make the pain better)
2) Is it related to particular time of day ? night
or certain position?
3) Do you have difficulty in lifting up objects?
4) Where exactly in your hand.( pt will show medial 3 and half finger)
(Carpal tunnel)
D/D / associated
1) do you have any neck pain( cervical disc herniation)
2) do you have any joint pain( RA) or predisposing factor
3) Do you have DM( diabetic neuropathy)
4) Does numbness increase in cold weather (Raynaud’s phenomenon)
5) Does heat and cold bother you more than others( hypothyroidism)
6) When was your LMP, Is it possible that you are pregnant

Neuro block

General Qs

Occupation (occupation of repetitive movement like secretary

Physical exam

1) 4 steps
2) Inspection( SEADS) wrist+finger+ cervical (will say consider it done)
No Bouchardfs nodes,No Swan neck deformity, Thenar & Hypothenar muscles equal
bulk
3) Palpation(TTCER)wrist+finger+cervical
4) Motor (neck, elbow ,wrist and hand)
5) Sensory (c2, c4, c5, c6-8)
6) Pulses
7) reflexes
8) Special test:
Tinel test: Tap on the aponeurosis in the middle of the wrist and ask do you
have numbness any where
Phallen test: do flexion of both wrist and oppose each other together then ask
do you have pain or numbness anywhere and comment.
Finkelstein test: Make a fist and put the thum in the fist with flexion at distal
phalanx of the thumb and do medial flexion and patient will have pain at Styloid
process of radius( Dequervan’s tenosynovitis or tenosynovitis of extensor pollicis
brevis and abductor pollicis longus)
Lhermitte test
Spurling test
Pronator drift
If you have time do
Cr 7th
Thyroid exam.

Diagnosis: Carpal tunnel

Investigation

a) Nerve conduction study

b) Blood sugar
c) Thyroid function test
d) Cervical xray
e) CT head
f) X-ray. Some doctors may recommend an X-ray of the affected wrist to exclude
other causes of wrist pain, such as arthritis or a fracture
g) Electromyogram
Treatment

a) Splints at night
b) Analgesic
c) Steroid injections
d) Surgery

35yr in the emergency has headache and confusion . pulse

80/min, B.P: 140/80 . TEMP; 40 Degree, RR: 23 . Do a physical
exam

1) 4 STEPS ( PT is lying down covering his eyes)

2) Neck rigidity, kerning’s and brudzinki sign, no scratch marks
3) Cranial nerves, 3,4,6( don’t forget opthalmoscope)
4) Motor
5) Sensory
6) Pulse
7) Reflexes + babiniski
8) Look for throat for infection
9) Eye
10) Nose no running nose, press on the sinus, ear discharge, I need to do otoscope.
11) Chest: listen to chest
12) LN
13) Skin; skin rash.
14) Heart: listen to heart

Investigation

a) CT Head
b) Blood culture
c) L.P
 Diagnosis: Meningitis
TTT: look for it
Look for table of LP in Toronto notes

55yr old had sudden weakness involving one side of his body.
So how he is stable . he regained his normal condition. Take a
history and do physical exam

1) OCD( As I can understand you loss your consciousness for how long. Did you
hurt yourself, what were you doing when it happened , anybody around you at
that time)
2) Before this attack
a) any bad news
b) any abnormal movement
c) Any blurring of vision
d) Any flashes of light
3) During the attack
a) You are able to hear during the attack
b) Did you have tongue bite
c) Did you loose control of your bowel and bladder
4) After the attack
a) Did you have weakness if yes then what part is involve and how long the
weakness lasted.
b) Loss of sensation
c) Blurring of vision

Neuro block

D/D
1) Any chest pain. SOB, feels heart racing , do you have heart
disease.( Arrythmia)
 2) Do you have history of epilepsy(Epilepsy)
3) Do you have any psychiatric disease any stress in life( Panic attack)

General; Qs

HTN, BS, smoking, DLP ( When was your last check up) Fhx of Migraine and stroke

Physical exam

1) 4 steps
2) Face: no asymmetry of face, normal nasolabial fold, no jaw deviation, examine
2,3,4,6 including pupils, light reflex, movement, ptosis , opthalmoscopy.
Complete examination of facial nerve and trigeminal nerve.
3) Neck: don’t forget the carotids listen, palpate
4) Motor( upper limb and lower limb)
5) Sensory( upper limb and lower limb)
6) Reflexes: as usual /babniski
7) Gait
8) Special test: Pronator drift

Investigations
1) CT Head
2) Carotid Doppler
3) EKG
4) Echocardiography
5) BS

Treatment
1) Life style changes( stop smoking, control B.P, BS ,DLP and regular
exercise)
2) Aspirin 325mg

18 yr old Jack Miller wants from you a letter to renew his

driving license which was discontinued because of seizure,
History and counsel him.
What brings you here today?
I need to make driving license and I need you letter.
Ok I will consider that but before I give you the letter I need to ask you some questions.
OCD:
1) Since when do you have epilepsy?
2) Have you been followed by doctor
3) Any investigation done before.
4) Do you take medication for that?
5) Do you take it regularly?
6) Does it control your symptoms?
7) How frequent you have the attacks
8) When was your last attack (It was 8 months ago and to give a letter for
driver license patient should be seizure free for 1 year)

Description of last attack

Before this attack

a) any abnormal movement
b) Any blurring of vision.
c) Any flashes of light
During the attack
a) Does it involve your whole body?
b) You are able to hear during the attack
c) Did you have tongue bite?
d) Did you loose control of your bowel and bladder
After the attack
d) Did you have weakness if yes then what part is involve and how long the
weakness lasted.
e) Loss of sensation
f) Blurring of vision
Side effect of phenytoin

Do you have thick gum, difficulty concentration, nausea and vomiting, hair loss, did
you notice that your eye is turning yellow

Side effects of Tegretol (Carbamazepine)

Unsteadiness, dizziness, drowsiness, dryness of mouth, headache, skin rash

increased weight, loss of appetite, nausea or vomiting, sexual problems (males)

Neuro Blocks

General Qs
Alcohol and sleep, Fhx of epilepsy
Financial problem

HEADSS

Counseling
Mr Miller I need to examine you and sent you for some investigation. As your last
seizure was 8 months ago. It will be difficult for me to give a letter. At this point driving
is not safe for you and others. I am obliged by law not to give you letter before 1 year of
seizure free period. Ministry of transportation must be informed about the time of
diagnosis and also about the follow up visit of patient. You should continue your
medication for at least 2 yr without seizure. Don’t do heavy work, don’t manipulate
heavy machine, don’t go to swimming pools alone .Take enough sleep, stop drinking
alcohol, do not lock the door when you take a shower. You have to consult your doctor if
you take any medications because phenytoin can interfere with the effects of other
medication.

I would suggest a family meeting if you do not mind

I will Send blood for serum Dilantin (phenytoin) levels if patient is on this already. If
Dilantin levels are therapeutic, but you are having severe side effects or poor seizure
control, a second drug may be added (usually carbamazepine or valproic acid)
There are support groups
Regular F/u, social worker for financial problem
Do you have any questions?

45 yr old male is complaining of things spinning around his

body.Take a focus history and do focus physical examination.

OCD does it come and go and for how long does it stay ) for seconds
What makes it worse: movement of head

Specific Qs
Is it related to particular time of the day
Is it related to particular activity like exercise
Is it related to particular position
Have you noticed anything with it like feeling sick and throwing up

D/D
1) any hearing loss.( Meniere’s disease, labyrinthitis).
2) Any noise in your ear. . ( Meniere’s disease, labyrinthitis
3) Any ear fullness. (Meniere’s disease, labyrinthitis)
4) Any ear discharge.(Meniere’s disease, labyrinthitis)
5) Any ear pain.( Meniere’s disease, labyrinthitis)
6) Do you have any headache.(stroke)
7) Do you have difficulty in vision.(stroke)
8) DO you have difficulty in speaking(stroke)
9) Loss of consciousness.(stroke)
10) Any weakness, loss of sensation(stroke)
11) Any abnormal movement in your hand( cerebellar involvement)
 12) Any abnormality of your gait.( cerebellum)
13) Do you have heart disease, chest pain, SOB, feel heart racing( Arrhythmia)
14) Do you take medication like Beta- Blocker, thiazide or other
antihypertensive medications
15) Do you have sudden onset of intense fear and discomfort stress, psychiatric
disease ( Panic disorder)
16) Do you have recent bleeding, vomiting and diarrhea( Volume loss)
17) How your mood

Neuro Blocks

General Qs

Physical exam

1) 4 steps( take B.P lying and standing)

2) examine the ear( no ear discharge, I need to do otoscopy)
3) Tongue : central cyanosis + dehydration
4) Cranial nerve# 2,3,4,6,7,8 and for cranial nerve for opthalmoscopy.
5) Gait
6) Cerebellar signs: British constitution, Finger to nose, Heel to shin,
dysdiadokinesia (Nystagmus and gait already done)
7) Motor
8) Sensory
9) Reflex
10) Dix Hall pike: pt should be sitting 45 degree, rotate the head to one side, hold the
head in this position let the patient lying down on the table with head hanging at
the end of the table. Wait few seconds, ask do you feel dizzy and see nystagmus
then let the patient sit and hold the patient head and comment on the eyes say no
nystagmus and say Dix hall pike –ve or + ve.

Five criterion of Dix hall pike maneuver

e) rotatory nystagmus
 f) reversible upon sitting
g) latency of 20 seconds
h) vertigo
i) Fatigue with repeated maneuver

Diagnosis: BPPV
Treatment;
Reassurance
Repositioning maneuver
Antiemetic

52yr old alcoholic. His gait is unsteady. Do a focus physical

exam

DD: Cerebellar ataxia, post column, stroke

1) 4 steps
2) Speech:- Say “ British constitution” and you say no slurred speech.
3) Cranial nerves 2,3,4,6 ,7, comment on nerves ,no nystagmus no facial asymmetry
4) Cerebellar signs:Finger to nose no intention tremors , no nystagmus and no past
pointing. No dysdiodochokinesia
5) Gait: Wide based gait
6) Special test;
a) Rhomberg’s test( position sense test)
b) Pronator drift test( UMN)
c) Sense of position( by big toe movement)
d) Vibration if you find tunning fork)

7) Motor system
8) Sensory system
9) Reflexes: babiniski
10) If time then tell the patient to write a sentence and comment no micrographia.
Note: If CT of brain: diagnose ring-enhancing lesion 1. Toxoplasmosis 2. Abcess 3.
Primary CNS lymphoma 4. TB 5. CMV