CN Exams Flashcards
(I) Olfactory Nerve
a) Ask about disorders of sense of smell and of taste (will diminish with loss of smell)
b) Using a penlight, make sure nostrils are not blocked.
c) Occlude one nostril at a time (eyes should be closed) Have patient sniff familiar and non-irritating odors, use the milder scent first.
Ask the patient:
1) Do you smell anything?
2) Can you identify the substance?
(II) Optic Nerve
a) Inspect external structures of eye
b) Inspect the optic fundi with ophthalmoscope
c) Test visual acuity Screen by reading print Screen with shapes and/or colors
d) Confrontation Test Examine directly in front and level with patient’s face Have patient cover one eye Bring object into view from eight different directions (P-A) per eye
e) Direct light reflex- ipsilateral pupillary constriction
f) Indirect light reflex (consensual reflex)- contralateral pupillary constriction
g) Accommodation reflex Test ability of the eyes to adapt for near vision Instruct patient to follow object inward from a distance Convergence of the eyes, constriction of the pupil
(III) Oculomotor, (IV) Trochlear, and (VI) Abducens Nerves
The following four tests are for CN III specifically:
a. Check for ptosis
b. Direct light reflex
c. Indirect light reflex
d. Accommodation reflex
The following will test CN III, IV, and VI combined:
a) Extraocular movements with six cardinal fields of gaze. Observe patient’s eyes for normal conjugate, or parallel movements of the eyes and nystagmus as you have him/her follow your finger or pencil while it makes a wide “H” in the air:
Trochlear = down and in Abducens = lateral Oculomotor all other fields.
(V) Trigeminal Nerve
a) Oculocardiac Reflex:
Take pulse, apply pressure over the patient’s closed eye, pulse rate should decrease 2-3 beats per 15 sec.
b) Test corneal reflex with wisp of cotton, should see blinking and tearing
c) Test pain (sharp pinprick) on face bilateral in all 3 divisions
(3 places per division for a total of 18 touches)
d) Test for light touch to the face with wisp of cotton or brush in all 3 divisions (3 places per division for a total of 18 touches)
e) Light touch to anterior 2/3 of tongue, inside cheeks, and hard palate with toothpick. (Use a penlight to view the inside of the mouth)
f) Have patient clench teeth, palpate masseter and temporalis muscles at rest & motion.
(VII) Facial Nerve
a) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirds of the tongue.
b) Inspect face for asymmetry (at rest and during motion)
Ask the patient to perform the following: Raise eyebrows Close eyes tightly Show teeth Puff out cheeks Smile Frown
(VIII) Vestibulo-Cochlear Nerve
Sensory-Cochlear Portion
a) Screening tests to confirm side of hearing loss:
Finger Rub Test:
Assess hearing by rubbing fingers together near the EAM, find maximal distance sound can be heard.
Whisper Test
Have patient close his eyes (to prevent lip-reading) and cover the ear on the side not being tested. Place your head/mouth 2 feet from the ear being tested and whisper words to the patient and ask patient to repeat the words. You can also ask questions to the patient and have the patient answer yes or no to each question.
b) Distinguish between perceptive and conductive hearing loss using a 512 Hz tuning fork by using Weber and Rinne tests
Weber Test
Procedure:
Place the handle of the vibrating tuning fork on the midline of the skull and ask the patient to compare the intensity of the sound in the two ears.
Indicates:
(-) Normal: sound is equal in both ears.
(+) Conductive deafness: sound lateralizes to the bad ear.
(+) Sensorineural deafness: sound lateralizes to the good ear.
Rinne Test
Procedure:
Place the handle of a vibrating tuning fork against the mastoid bone for bone conduction. Begin counting or timing the interval with a watch. Ask the patient to tell you when the sound is no longer heard, noting the amount of time. Then quickly hold the vibrating fork near the external ear canal without touching the patient (.5 to 1”) for air conduction, and again have the patient indicate when the sound ceases. Again, note the amount of time. Indicates:
Normal: air conduction persists twice as long as bone conduction Abnormal: Conduction deafness: air conduction is absent, equal to, or less than bone conduction. Abnormal: Sensorineural deafness: air conduction and bone conduction are both radically decreased or absent.
Fukuda Step Test
Procedure:
Patient marches in place, eyes closed for 50 steps.
Positive:
A turning to one sideIndicates: Vestibular lesion on the side of rotation
Hallpike Dix Maneuver
Procedure:
Patient is seated with head turned 45º to the right or left. Examiner quickly brings the patient into the supine position with head extended off the table. Examiner notes any nystagmus. Patient is then brought to the seated position. Repeat with head turned to the opposite direction.
Positive:
Nystagmus starting 2-5 seconds after movement and stopping within 30 seconds. Indicates: Benign positional vertigo
Barany Whirling Chair Test
Procedure:
Seated patient is spun in chair in one direction
Indicates: Normal:
fast component of nystagmus will be in the direction of the spin.
Vestibulo-ocular Reflex
Procedure:
Dr. holds patient’s head and instructs patient to fix vision on the doctor’s face. Observe and note spontaneous nystagmus. Dr. then turns patient’s head into rotation, lateral flexion, and flexion and extension.
Indicates:
Normal patient should maintain eye contact eyes moving at the same speed in the opposite direction of head movement. Inability to maintain fixation or spontaneous nystagmus indicates a vestibular lesion.
(IX) Glossopharyngeal and (X) Vagus Nerve
a) Note any hoarseness of the voice.
b) Ask the patient about change in bitter taste sensation on the posterior third of the tongue.
c) Uvula reflex = Patient says “ah” while doctor shines light in mouth and depresses tongue as necessary Watch for symmetrical rising of soft palate. Unilateral paralysis = One side of palate does not rise and uvula deviates to the normal side.
d) Gag reflex.
e) Have patient swallow while you palpate thyroid cartilage.
f) Carotid sinus reflex
(XI) Spinal Accessory Nerve
a) Trapezius Muscle Inspect Palpate Muscle test
b) Sternocleidomastoid Muscle Inspect Palpate Muscle test - Ask patient to rotate head to one side. Dr. instructs patient to hold, while Dr. attempts to return the head to neutral.
(XII) Hypoglossal Nerve
a) Inspect tongue for:
1. Atrophy
2. Fasciculations
3. Deviation b) Have patient stick out tongue and test bilateral with tongue depressor, or use the tongue in cheek method
Unilateral paralysis = Protruded tongue deviates to involved side.
