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OSCE > Cranial Nerve Exam > Flashcards

Cranial Nerve Exam Flashcards

1
Q

What is CN I (1)?

A

Olfactory Nerve

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2
Q

What is CN II (2)?

A

Optic nerve

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3
Q

What is CN III (3)?

A

Occulomotor nerve

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4
Q

What is CN IV (4)?

A

Trochlear nerve

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5
Q

What is CN V (5)?

A

Trigeminal nerve

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6
Q

What is CN VI (6)?

A

Abducens nerve

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7
Q

What is CN VII (7)?

A

Facial nerve

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8
Q

What is CN VIII (8)?

A

Vestibulocochlear nerve

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9
Q

What is CN IX (9)?

A

Glossopharyngeal Nerve

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10
Q

What is CN X (10)?

A

Vagus nerve

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11
Q

What is CN XI (11)?

A

Spinal accessory nerve

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12
Q

What is CN XII (12)?

A

Hypoglossal nerve

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13
Q

How should you first assess a patient’s cranial nerves?

A

General inspection

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14
Q

What is the pathology?

A

Bell’s Palsy (unilateral facial nerve weakness)

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15
Q

What is the pathology?

A

Stroke (UMN lesion affecting the facial muscles)

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16
Q

How can Bell’s be differentiated from a facial stroke?

A

Forehead sparing in stroke

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17
Q

Why is there forehead sparing in stroke?

A

Bilateral UMN supply to the superior part of the facial nerve nucleus

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18
Q

What should be looked for in eyes on general inspection?

A
  • Strabismus
  • Ptosis
  • Asymmetrical pupil
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19
Q

What is this sign?

A

Ptosis

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20
Q

What is this sign?

(Not the ptosis)

A

Miosis (pupil constricted)

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21
Q

What is this sign?

A

Mydriasis (pupil dilation)

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22
Q

How can you distinguish unilateral miosis from unilateral mydriasis?

A

The normal pupil should be more constricted in brighter light

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23
Q

What abnormality of speech is relevant to a cranial nerve exam?

A

Dysarthria (problems with articulation)

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24
Q

What signs of cranial nerve problems can be seen around the bedside?

A
  • Glasses
    • Hearing aids
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25
Q

How can the function of the olfactory nerve be assessed?

A

Ask if they have had any changes to their sense of smell

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26
Q

What are the aspects of a full optic nerve assessment?

(Doing all of these in an exam is excessive unless specifically asked to)

A
  • Pupil inspection
  • Visual acuity
  • Pupillary reflexes
  • Colour vision
  • Visual fields
  • Fundoscopy
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27
Q

What are the essential aspects of an optic nerve assessment?

A
  • Pupil inspection
  • Visual acuity (brief tests of ability to read/see)
  • Visual fields
  • Fundoscopy (may not be needed)
  • Pupillary reflexes (also CN III)
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28
Q

What aspects of optic nerve assessment can be modified or excluded for OSCE purposes?

A
  • Visual acuity - not always necessary to do full Snellen chart
  • Colour vision - exclude in most exams
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29
Q

What is the pathology*?

A

Anisocoria (unequal pupil size) - in this case, mydriasis

*Up to 20% of people are born with very mild anisocoria

(Fun Fact: David Bowie developed anisocria when a friend damaged his iris in a fight)

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30
Q

What is the type of anisocoria and what is the likely cause?

A

Mydriasis - CN III lesion

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31
Q

What is the type of anisocoria and what is the likely cause?

A

Miosis - Horner’s syndrome

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32
Q

How can visual acuity be tested in an OSCE?

A

Ask the patient to cover one eye at a time and read a part of a book or magazine

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33
Q

Should patients be given their glasses when testing visual acuity?

A

Yes

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34
Q

What can be used to more formally test visual acuity?

A

Snellen chart

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35
Q

If performing fundoscopy as part of a cranial nerve exam, what aspects should be included?

A
  • Red reflex
  • Retinal visualisation
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36
Q

Which eye should be used to look in the patients left eye?

A

Left (and vice versa)

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37
Q

How can visual fields be assessed?

A
  • Sit/stand level with the patient
  • Ask them to cover one eye and cover/close your corresponding eye
  • Hold finger at the edge of your visual fields (2/4/8/10 o’clock positions) midway between you and the patient and ask the patient if they can see your finger moving
  • Repeat with the other eye
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38
Q

What shows a visual field defects in a cranial nerve exam?

A

Needing to move your finger in from where you can see it so that the patient can see it

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39
Q

What is the name of and what can cause this sort of visual field defect?

A
  • Monocular blindness
  • Optic nerve or retinal lesion
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40
Q

What is the name of and what can cause this sort of visual field defect?

A
  • Bitemporal hemianopia
  • Lesion at the optic chiasm
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41
Q

What can cause a lesion at the optic chiasm?

A

Pituitary tumour

42
Q

What is the name of and what can cause this sort of visual field defect?

A
  • Right homonymous hemianopia
  • Lesion of the optic tract
43
Q

How should CN 3,4 and 6 be tested?

A

Testing ocular movements

44
Q

What shape should a patient be made to follow to test ocular movements?

45
Q

What should be observed for on eye movement testing?

A
  • Restricted movement
  • Nystagmus
46
Q

What is shown here?

47
Q

Palsy of which nerve is seen here?

48
Q

Palsy of which nerve is seen here?

A

Oculomotor nerve

49
Q

Palsy of which nerve is seen here?

A

Trochlear nerve

50
Q

Which tests for

51
Q

What are the tests of pupillary reflexes?

A
  • Accommodation reflex
  • Direct pupillary reflex
  • Consensual pupillary reflex
  • Swinging light test
52
Q

How is the accommodation reflex tested?

A
  • Ask patient to look into the distance
  • Hold a pen a few cm in front of their nose
  • Ask them to look at the tip of the pen
53
Q

What should be seen on normal accommodation?

A
  • Convergence of the eyes
  • Constriction of the pupils
54
Q

How are the direct light reflexes tested?

A
  • Hold hand down midline
  • Shine light into one eye and observe it for constriction
  • Repeat with the other eye
55
Q

How are the consensual light reflexes tested?

A
  • Hold hand down midline
  • Shine light into one eye and observe the other for constriction
  • Repeat with the other eye
56
Q

How is the swinging light test performed?

A
  • Swing pen torch from one eye to the other
  • Observe for dilation of the pupils when light shone in one pupil
57
Q

What does the swinging light test assess for?

A

RAPD (relative afferent pupillary defect or Marcus Gunn Pupil)

58
Q

What does dilation of pupils when swinging light onto a pupil?

A

The pupil that the light is being shone into has an RAPD

59
Q

Which nerves are involved in the light reflexes?

60
Q

If there is absence of direct reflex but presence of consensual, which nerve is affected?

61
Q

If there is absence of direct and consensual reflexes in one eye, which nerve is affected?

62
Q

If there is loss of consensual reflex only which nerve is affected?

A

The contralateral 2nd nerve

63
Q

How is the sensory aspect of the 5th nerve tested?

A
  • Test light touch in the opthalmic, maxillary and mandibular divisions
  • Compare left to right
64
Q

Which muscles are supplied by the motor aspect of the trigeminal nerve?

A

Muscles of mastication

65
Q

How is the temporalis muscles tested?

A

Ask patient to clench teeth whilst feeling temple area

66
Q

How is the masseter muscle tested?

A

Ask patient to clench teeth whilst feeling over cheeks

67
Q

How are the pterygoid muscles tested?

A

Ask the patient to open their mouth and resist you closing

68
Q

If there is pterygoid weakness, what will be seen on examination?

A

Deviation to the side of weakness when opening the mouth

69
Q

How is the facial nerve tested?

A

Ask the patient to perform specific movements of the muscles of facial expression

70
Q

What muscles should be tested when assessing the function of the facial nerve?

A
  • Frontalis
  • Orbicularis oculi
  • Orbicularis oris
  • Buccinator
71
Q

How is the frontalis muscle tested?

A

Ask the patient to raise their eyebrows

72
Q

What unilateral weakness of the frontalis muscle suggest?

A

LMN lesion

73
Q

What does unilateral weakness of all muscles of facial expression except frontalis suggest?

A

UMN lesion

74
Q

How is orbicularis oculi tested?

A

Ask the patient to screw their eyes closed and resist you opening

75
Q

How is orbicularis oris tested?

A

Ask the patient to grin 😀

76
Q

How is the buccinator muscle tested?

A

Ask the patient to puff out their cheeks and resist you pushing them in

77
Q

How can the vestibulocochlear nerve be tested?

A
  • Whisper a number in the paitent’s ear and ask them to repeat it
  • Weber’s test
  • Rinne’s test
78
Q

What is Weber’s test?

A
  • Place a tuning fork on the patient’s forehead
  • Ask them which ear it localises to if any
79
Q

What does localisation of Weber’s test suggest?

A

Asymmetrical hearing loss

80
Q

Where does the sound localise to in an asymmetrical sensorineural hearing loss in Weber’s test?

A

The unaffected ear

81
Q

Where does the sound localise to in an asymmetrical conductive hearing loss in Weber’s test?

A

Affected ear

82
Q

What is Rinne’s test?

A
  • Place the tuning fork on the mastoid process and ask them to tell you when it stops
  • Move fork to in front of ear and ask if they can still hear it
83
Q

What result of Rinne’s suggests conductive hearing loss?

A

Unable to hear once moved from mastoid

84
Q

What suggests sensorineural loss in Rinne’s test?

A

Able to hear sound when moved from mastoid process (in the ear that sound localised away from in Weber’s test - will show the same Rinne result in normal ear)

85
Q

What are the Bulbar cranial nerves?

86
Q

How should the bulbar nerves be tested?

A
  • Cough
  • Articulation
  • Examine pharynx
  • Tongue movements
87
Q

What cranial nerve is tested by asking the patient to cough?

A

10 (vagus)

88
Q

How can articulation be tested?

A

Ask the patient to say the days of the weeks

89
Q

What nerves are involved in articulation?

90
Q

How is the pharynx examined?

A
  • Use a tongue depressor and pen torch
  • Ask the patient to say ahh and observe uvula
  • Remove tongue depressor
  • Ask to swallow
91
Q

Where does the uvula deviate in a CN IX or X lesion?

A

Away from the lesion on saying ahh

92
Q

What is not normally tested in a conscious patient?

A

Gag reflex

93
Q

How is CN 12 tested?

A
  • Ask the patient to stick their tongue out
  • Observe for wasting
  • Move side to side
  • Push tongue into side of cheek and apply resistance
94
Q

What indicates a CN 12 lesion?

A

Deviation towards the lesion

95
Q

How is the CN 11 tested?

A
  • Ask patient to shrug their shoudlers against resistance
  • Ask the patient to turn their head against resistance
96
Q

Which muscle provides shoulder shrugging?

97
Q

Which muscle provides head turning?

A

Sternocleidomastoid

98
Q

What additional tests can be considered after a cranial nerve exam?

A
  • Neuro exam of the limbs
  • Gait and balance
  • CT/MRI head
99
Q

What is shown here?

A

Left CN XII lesion

100
Q

What is shown here?

A

Left CN IX or X lesion

OSCE (19 decks)

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