Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) Central Nervous System CVS Notes Handwritten Notes
INTRODUCTION
1. Name
2. Age
3. Sex
4. Handedness
5. Resident of
6. Education
7. Occupation
8. Informant
9. Reliability
CHIEF COMPLAINTS
1. Xxxxxx ? Onset and course
2. Yyyyyy ? onset and course
3. Zzzzzzz ? onset and course
H/O PRESENT ILLNESS
1. LOC/Seizure
a. Onset
b. Activity at the time of incident
c. Preceded by
i. Chest pain/Palpitationsweating/nausea/ vomiting/
i . headache/giddiness/presyncope/visual
disturbance.
d. Associated with
i. Involuntary movt/Tonic/clonic/focal/generalized
i . Rol ing up of eyes/stare/tongue bite/grunting noise
i i. Sphincter incontinence/abnormal breathing pattern
e. Lasted for (Duration)
f. Recovered after ? Spont/treatment
g. Post recovery ? drowsiness/confusion/weakness
h. Number of episodes
i. Sensorium in between episodes
j. Last episode
k. Any injury sustained.
2. Disorientation
a. To T/P/P
b. Episodic or continuous
c. Orientation between the episodes
d. Any abnormal behavior
e. Recovery
3. Speech disturbance
a. Onset
b. Comprehension
c. Any spontaneous speech/word outflow
d. Slurring
e. Reading/writing/repetition
f. Progression
g. Any stress during speaking
h. Tightness/looseness in tongue
i. Paraphasias
4. Cranial Nerves
I. Smel to commonly used items
soap/shampoo/toothpaste
II. Decreased visual acuity
Color vision
Color desaturation
Scotoma/Field defect
III. IV and VI
i. Double vision
1. Monoocular/binocular
2. On primary gaze or evoked gaze
3. Horiontal/vertical
4. Disappears by (Closing eye)
i . Pain in eyes on movements
i i. Ptosis ? Fatiguability/diurnal variation
iv. Features of Horners syndrome
IV. Same as above
V. Decreased/abnormal sensations over face, dif iculty
in mastication.
VI. Same as above
VII. Deviation of angle of mouth
Facial asymmetry
Drooling of saliva
Dif iculty in closing eyes
Dif iculty in speaking
Taste impairment
VIII. Hearing impairement
Giddiness
Vertigo
Tinnitus
H/O CSOM
IX. And X
Dysphagia ? solid/liquid/both
Dysphonia
Dysarthria
Nasal regurgitation
Hoarseness of voice/Nasal twang
X. Same as above
XI. Neck movements
Shrugging of shoulders
XII. Ability to make the bolus of food
Ability to maneuver the food bolus inside the mouth
Tongue deviation
Dysarthria
5. Motor
a. Weakness (UMN)
i. Reaching overhead objects/taking comb to the head
i . Lifting a bucket of water/breaking the chapaties
i i. Holding a glass of water/writing task in detail
iv. Holding the pen/grasping the comb
v. Dif iculty in getting up from a chair/squatting
position
vi. Climbing up/down the stairs/gripping the chappals
vii. Chappals slips away with/without the knowledge
vii . Getting up from lying down position/Turns in the
bed
ix. Lifting the head of the bed
x. Breathlessness/ptosis/facial weakness/chewing
b. Dexterity
i. Buttoning/unbuttoning the shirt/ Breaking the
chapaties
i . Tie the nada of payjama/shoe lace
i i. Negotiating the foot into the chappal
iv. Also ask about
1. Proximal/distal
2. Symmetrical/asymmetrical
3. Spasticity/wasting ? which is more?
4. Onset and progression of the weakness
5. Present status.
c. Weakness (LMN)
i. Looseness/fasciculations/wasting
i . Which is earlier ? weakness or wasting
i i. Proximal/distal
iv. Symmetrical/asymmetrical
v. Periodicity/diurnal variation, fatiguability
vi. Selectivity of muscles
vii. Onset/course/progression
d. Cerebel ar
i. Smearing of face/target oriented activities
i . Tremors/Gait/Speech/Vertigo/Looseness of limbs
i i. Dif iculty in reaching the objects
iv. Incoordination during picking up water/during
drinking.
e. EPS
i. Tremors at rest/Stif ness/expressionless face
i . Bradykinesia ? during bath/dressing etc.
i i. Sleep/Memory/Handwriting/Hypophonia/Gait
iv. Dif iculty in walking narrow paths (Pedestrian strip)
f. Gait
i. Broad based/Narrow base
i . Speed/Antalgic gait/Freezing/Parkinsons gait
features
i i. Recurrent fal s/Buckling........./Climbing up/down
iv. Dif iculty in walking in dark/Pain while walking
v. Stif ness/crossing of legs
6. Sensory
a. Onset/progression/present status
b. Posterior column
i. Unable to feel clothes over the body
i . Dif iculty in walking in the dark/wash basin (Sink)
sign
i i. Slipping of slippers without knowledge
iv. Cotton wool sensations over the feet
v. Band like sensation/Encasement of limbs
vi. Pins and needles/numbness/tingling/paraesthesias
vii. Lhermittes phenomenon/water flowing underneath
the feet
c. Spinothalamic
i. Hot and cold water during bath
i . Burning/shooting/pricking pain
i i. Funicular pain/sensory level
iv. Root pain is a sharp shooting pain in a particular n
dermatomal
pattern
which
increases
on
coughing/sneezing. It is recurrent and more severe.
d. Cortical sensations
i. Ability to feel the coins in the pocket
i . Feel wal et in the pocket
7. Autonomic
a. Bladder
i. Urgency/urge incontinence/frequency/hesitancy
i . Precipitancy/Retention
(Painful/less
&
aware/unaware)
i i. Overflow incontinence/incomplete evacuation
iv. Dribbling of urine/loss of social inhibition
v. Postural giddiness/presyncope/erectile dysfunction
b. Bowel ? Frequency/consistency/continence
c. Faintness/palpitations
d. Abnormal sweating/Decreased lacrimation
e. Horners syndrome
f. Gastroparesis/nausea/vomiting/diarrhea
ETIOLOGICAL HISTORY
1. Headache (Mnemonic ? OLD CAARTS)
a. Onset/location/duration/diurnal variation/Ch.......
b. Associated with(Nausea/vomiting/photophobia/
phonophobia/ abnormal behavior/LOC/blurring of vision
c. Red flag signs
d. Preceded by aura
e. Aggravated by/relieved by/timing/severity/
f. Frequency (No of episodes in a day)/abnormal
sweating
g. Pain anywhere in the body
2. Injury/RTA/Trauma to the neck
3. Abnormal behavior/nausea/vomiting
4. Fever/chest pain/palpitations/cough/
dyspnea/hemoptysis
5. Bowel symptoms/Jaundice
6. Oliguria/dysuria/hematuria/high colored urine
7. Joint pain/rash/photosensitivity/oral ulcers
/hair fal /seizures
8. Dog bite/animal bite/vaccination/injection
9. Alternative drugs/wel water drinking/insecticides
exposure
10. Carrying weight in head for long/neck pain for long
11. Skin lesions/Nodules
12. Hypo/hyper thyroidism symptoms
13. Blood transfusion
PAST HISTORY
1. DM/TB/HTN/Hansens/CAD/BA
2. Similar il ness in the past
3. Animal bite/vaccination/injection in the past
4. Blood transfusion/jaundice
5. Major surgery
PERSONAL HISTORY
1. Veg/Non veg/Wel water drinking/food habits
2. Smoking/Tobacco/Alcohol/Substance abuse
3. Marriage/Children
4. High Risk behavior
MENSTRUAL HISTORY
1. Menarche/Cycles/Menopause
2. LMP/Post menopausal bleed
3. any surgery
OCCUPATIONAL HISTORY
1. Nature/duration/intensity of exposure
2. H/O exposure to dye/paint/glasswares/med
eqpts/jwel ery
3. Plumbing/farming/insecticides
4. Vibrating eqpts/repeated trauma
FAMILY HISTORY
1. Pedigree charting of possible genetic disease
2. h/O similar il ness in the family
TREATMENT HISTORY
SUMMARY at the end of history and four tier diagnosis
1. Functional
2. Physiological
3. Anatomical
4. Etioloical 1, 2, 3, 4......
GENERAL EXAMINATION
1. Conscious/oriented/cooperative/comfortably lying.........
2. Ht/Wt/BMI/Arm length/upper segment/lower segment/neck:ht
ratio.
3. Pulse
Rate/rhythm/volume/character/peripheral pulses/R-R & R-F
Delay/pulse deficit/vessel wal /carotid bruit/shudder
4. BP
mm Hg/Rt Arm supine/No significant postural fal
5. RR ? rate/rhythm/type
6. P/I/C/C/L/E/JVP
7. Neurocutaneous markers
8. Nerve thickening
9. Vitamin deficiencies
10. Xanthoma/xanthelasma/arcus senilis
11. Congenital anomalies ? arms/foot/chest/gums/teeth/hair change
12. acanthoma nigricans/scars/sinus
13. Features of hypo/hyper thyroidism
14. acromegaly/marfans features
15.
Angioma/cutaneous
angiomata/rash/petechiae/purpurae/ecchym.
16. Bed sores/genital ulcers
17. Peripheral stigmata of TB/HIV
SYSTEMIC EXAMINATION
1. CVS
a. Apical Impulse/chest wal symmetry/anomalies
b. S1/S2/S3/S4/murmur/pericardial rub/knock
2. RS
a. Chest wal symmetry
b. Air entry/Breath sounds/adventitious sounds/pleural rub
3. P/A
a. Distended/al quadrants moves equal y with the respiration
b. Soft/Non tender/organomegaly/free fluid/bowel sounds
c. Hernial sites/peripheral signs of liver failure
CNS EXAMINATION
1. HMF
a. consciousness
b. oriented to T/P/P
c. Registration
d. attention/calculation
e. Recal
f. Language-Speech (Mnemonic ? CNS R3)
i. Comprehension
i . Naming
i i. Spontaneous speed
iv. Reading
v. Writing
vi. Repetition
g. Language ? Dysarthria
i. UMN/Pseudobulbar ? "British constitution"
i . Bulbar ? Pa Ta Ka
i i. Cerebel ar ? Rashtrapaty Amritsar se Hyderabad gaye
Ask to repeat "Yel ow Lorry".
iv. Tongue muscles fasciculations/flaccidity.
v. NMJ ? Fatiguability/Nasal voice.
2. Cranial Nerves
I
- Cof e powder/soap/shampoo/tooth paste
II
- Acuity/Color/field/pupils/RAPD/Fundus.
III/IV & VI
- Position of the eye at primary gaze
- Conjugate eye movements
a. convergence/divergence/saccades/pursuits
- Individual eye movements
- Nystagmus
V
- Facial sensations touch/pain/temp/vibration
- Muscles of mastication- clench the teeth
- Movements of mandible
- Corneal reflex
- Jaw reflex
VII
- Wrinkling of forehead
- Frowning of eyebrows/eyelid closure
- Bel s phenomenon/facial expression/nasolabial fold
- Angle of mouth deviation/buccinators
- Taste sensation ant 2/3rd ? sugar/vinegar/salt
- Parotid swel ing/tenderness
- Herpes zoster in EAM
VIII
- Rinnes/webers/ABC/Ear examination
IX & X
- Uvular position
- On saying "AH" uvula/palatal/post phar. wal
movement
- Gag reflex
- Taste on post 1/3rd of tongue
- Dysphonia/dysphagia testing (?????)
XI
- Shrugging of shoulders
- Left/right turn of neck (SCM)
XII
- Tongue position in resting state/on protrusion
- Flaccidity/fasciculations/tremors/spasticity
- Myotonia/movements/Deviation of tongue
3. Motor system examination
a. Position/attitude of limbs
b. Bulk (wasting/hypertrophy)
c. Tone
i. Spasticity ? clasp knife
i . Rigidity ? cog wheel/lead pipe
i i. Flaccidity
iv. Fasciculations
d. Power
i. Shoulder ? Abduction/adduction/flexion/extension (5/5)
i . Elbow ? Flexion/extension (5/5)
i i. Wrist ? Dorsiflexion/Palmar flexion (5/5)
iv. Hand grip ? Percentage (25/50/75), Myotonia (+/-)
v. Individual muscles of hand ? Normal or weak.
vi. -------
vii. Hip - Abduction/adduction/flexion/extension (5/5)
vii . Knee - Flexion/extension (5/5)
ix. Ankle ? Dorsiflexion/Plantar flexion (5/5)
x. EDP muscle wasting ? Present/not
xi. Truncal weakness ? Percentage (25/50/75)
xii. Neck muscle weakness - Percentage (25/50/75)
(Flexion/extension/lateral flexion)
e. DTR
i. Biceps/triceps/supinator/knee/ankle
i . Clonus (+/-)
i i. Myotonia (+/-)
iv. Pseudomyotonic reflex
f. Superficial Reflexes
i. Plantar
i . Abdominal
i i. Cremastric
iv. Perianal reflex
g. Whartenburg sign
h. Kof man sign
j. Release reflexes
i. palmo mental
i . Glabel ar tap
i i. Rooting reflex
iv. Suckling reflex
v. Grasping reflex
k. Coordination ? UL/LL
4. Sensory System Examination
a. Superficial sensations
i. First test pin prick sensation
i . Touch
b. Deep sensations
i. Pain
i . Temperature ? Cold (Tuning fork) and warm
c. Combined
i. Vibration
- Forehead/Mastoid/Sternum/Vertebral spine
- Clavicle/Elbow/wrist
- ASIS/PSIS/Tibial tuberosity/ankle
i Joint position
- Great toe/index finger
d. Cortical sensations
I al the peripheral sensations are intact, then, check for
cortical sensations.
e. Lhermittes phenomenon
f. Rhombergs sign
g. determine pattern of sensory loss
i. Symmetrical/asymmetrical
i . Glove stocking/Patchy
i i. Root level
5. Cerebel um
a. Nystagmus
i. Primary gaze
i . evoked gaze
i i. Horizontal/vertical/torsional
iv. Fatiguable/not
b. Intention tremor
c. Rebound phenomenon (Holmes)
d. Dysmetria
(these tests to be done with eyes open and then eyes
Closed and initial y slow & then rapid)
i. Finger nose test
i . Finger nose finger
i i. Knee shin dragging test
- First tap the knee with heel to r/o sensory loss
- Then excursion along skin of the tibia
(Cerebel ar ? broken movements)
(Sensory ? waving of heel here & there)
iv. Finger toe test
e. Past pointing
f. Alternating movements
i. Draw a circle in air with finger/toe
i . Alternatively pat the foot steadily on the ground
i i. Pronation ? supination (Disdiadochokinesia)
iv. Alternating opening and fisting of both hands
v. Screwing like movements
vi. Door knob opening like movements
vii. Opposition of thumb and fingers
vii . Tap out simple rhythm with finger.
g. Speech
h. Hypotonia
j. Pendular knee jerk
k. Titubation
l. Gait and how the patient stands
m. Drift
i. Cerebel ar ? Upward
i . Pyramidal ? Down and pronated
i i. Parietal lesion ? Upward and wavy
6. Gait
7. EPS
a. Rigidity
b. Tremor
c. Mask like face
d. Gait
e. Micrographia
f. Hypophonia
g. Hypomimia
8. ANS
a. Postural hypotension
b. Sweating
SUMMARY At the end of examination
FOUR TIER DIAGNOSIS
This post was last modified on 11 August 2021