Clinical skills: cranial nerve exam

Question 1

Initial approach?

Answer 1

Hand hygiene
Regular six steps
Ask patient if they are in any pain of discomfort

Question 2

Steps?

Answer 2

General inspection
Vital signs
Cranial nerves

Question 3

General inspection?

Answer 3

Scars + evidence of past intracranial surgery
Rash
Lesions

Facial asymmetry
Speech/voice issues

Question 4

Cranial nerve I (olfactory)

Answer 4

Inspect the nose
Ask about smell
Test smell (don’t do)

Question 5

Cranial nerves II (optic), III (oculomotor), IV (trochlear), VI (abducens)
- General inspection

Answer 5

Ptosis
Proptosis
Unequal pupils
Squint
Ask about visual aids

Question 6

Cranial nerves II (optic), III (oculomotor), IV (trochlear), VI (abducens)
- 4 tests to look at CN II only?

Answer 6

Visual acuity (Snellen chart)
Colour vision (Isihara plates)
Visual field
Mapping the blind spot

Question 7

Cranial nerves II (optic), III (oculomotor), IV (trochlear), VI (abducens)
- 2 tests to look at CN II (afferent) and CN III (efferent)?

Answer 7

• Accommodation
• Pupillary light reflex: direct, indirect, afferent defect

Question 8

Cranial nerves II (optic), III (oculomotor), IV (trochlear), VI (abducens)
- Test for eye movement (nerves III, IV, VI)?

Answer 8

H shape
Look for nystagmus, ask about diplopia

Question 9

Cranial nerves II (optic), III (oculomotor), IV (trochlear), VI (abducens)
- Additional test?

Answer 9

Ophthalmoscopy

Question 10

Cranial nerve V:
- Inspection

Answer 10

Wasting and asymmetry of the masseter and temporalis

Question 11

Cranial nerve V
- Sensory tests?

Answer 11

Corneal reflex (sensory 5, motor 7)
Light and sharp touch - across the opthalmic, maxillary, mandibular branches

Question 12

Cranial nerve V
- Motor tests?

Answer 12

Palpation of the temporalis, pterygoid, masseter
Jaw jerk reflex

Question 13

Cranial nerve VII
- Inspection

Answer 13

Facial asymmetry

Question 14

Cranial nerve VII
- Sensory?

Answer 14

Taste - anterior 2/3 of the tongue

Question 15

Cranial nerve VII
- Motor

Answer 15

Muscles of facial expression

Question 16

Cranial nerve VIII (acoustic/vestibular)
- Inspection?
- Asks about?

Answer 16

Ear; hearing, balance
Any changes to hearing or balance?

Question 17

Cranial nerve VIII
- Tests

Answer 17

Rinnie’s test
Weber’s test
Whisper test
(Hall pike manouevre)

Question 18

Cranial nerve IX/X - glossopharyngeal/vagus
- Inspection?

Answer 18

Hoarseness of voice
Bovine cough
Displacement of uvula

Question 19

Cranial nerve IX/X - glossopharyngeal/vagus
- Tests?

Answer 19

Taste at posterior 1/3 of tongue
Gag reflex

Question 20

Cranial nerve XI - accessory
- Inspection?

Answer 20

Wasting/deformity of the shoulders and neck

Question 21

Cranial nerve XI - accessory
- Tests

Answer 21

Trapezius: shrug shoulders against mild resistance
Sternocleidomastoid: turn head against resistance

Question 22

Cranial nerve XII - hypoglossal
- Inspection

Answer 22

Tongue asymmetry, wasting, fasciculations

Question 23

Cranial nerve XII - hypoglossal
- Tests

Answer 23

Tongue deviation when poked out