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YR3: OSCE > Cranial Nerve Examination > Flashcards

Cranial Nerve Examination Flashcards

1
Q

How would you briefly test CNI?

A

Askif they have noticed any recentchanges to or loss ofsenseofsmell.

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2
Q

How would you formally test CNI?

A

Use different scented bottles, 1 notstril at a time (e.g. lemon, peppermint)

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3
Q

What is the mnemonic for the ways of testing CNII?

A 
Afro BC
Acuity
Fields
Reflexes
fundOscopy
Blind spot
Colour vision
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4
Q

What is used to test visual acuity?

A

Snellen Chart
Ask to cover 1 eye + read the lowest line theyare able to.
Record the lowest line they were able to read
Numerator= distance from chart
Denominator= distance at which a normal eye can read

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5
Q

How do you test visual fields?

A
  1. Sit 1m opposite pt
  2. Ask to cover 1 eye with their hand, mirror them(pt covers right eye, you cover your left)
  3. Ask pt to focus on part of your face (e.g. nose) + not move their head or eyes during the assessment. Do the same + focus your gaze on the pt’s face.
  4. For central visual field loss or distortion, ask pt if any part of your face is missing or distorted.
  5. Position hatpin (or finger) at anequal distancebetween you + pt
  6. Start from the periphery + slowly move the target towards the centre, asking pt to report when they 1st see it. If you see the target but the pt cannot: suggests patient has a reduced visual field.
  7. Repeat for each quadrant, then repeat for the other eye.
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6
Q

How do you test for visual neglect?

A
  1. Sit 1m opposite pt
  2. Ask pt to remain focused on a fixed point on your face+ to state if they see your left, right or both hands moving.
  3. Hold your hands out laterally with each occupying one side of the patient’s visual field (i.e. left + right).
  4. Wiggle a finger on each hand to see if pt is able to correctly identify which hand has moved.
  5. Wiggle both fingers simultaneously to see if pt is able to correctly identify this (often pts with visual neglect only report the hand moving in the unaffected visual field – i.e. contralateral to the primary brain lesion).
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7
Q

How do you test the direct pupillary reflex?

A

Shine light into pt’s pupil + observe for pupillary constriction in theipsilateraleye.

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8
Q

How do you test the consensual pupillary reflex?

A

Shine light into the same pupil + observe for pupillary constriction in thecontralateraleye.

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9
Q

Describe the test for RAPD

A

Move light rapidlybetweenthe2 pupils
Still get normal direct + consensual reflex, may not be as good constriction as in a normal reflex- not seen until comparing both
Defected eye gives apparent dilatation
both pupils constrict when light swings to undamaged side, both pupils paradoxically dilate when light swings to damaged side.

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10
Q

How do you test the accommodation reflex?

A
  1. Ask pt to focus on a distant object
  2. Place your finger ~20-30cm in front of their eyes
  3. Ask pt to switch from looking at the distant object to the nearby finger/thumb.
  4. Observe the pupils, you should seeconstriction + convergence bilaterally.
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11
Q

What else do you offer to perform in assessment of CNII?

A 
Fundoscopy to check the optic disc.
Blind spot
Colour vision (Ishihara plates)
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12
Q

How is the function of extrinsic muscles of the eye tested in a clinical setting?

A

Stand in front of patient + ask them to follow your finger with their eyes without moving their head

Draw a “H” with your finger to test all muscles in the eye

At the end, bring your finger directly in towards the patient’s nose. This will cause the patient to look cross-eyed + the pupils should constrict (accommodation)

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13
Q

Give 3 causes of ptosis

A

Oculomotornerve pathology
Horner’s syndrome
Neuromuscular pathology (e.g. myasthenia gravis)

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14
Q

Describe the appearance of a 3rd nerve palsy with reason

A

Unopposed action of LR + SO
Down + out
Ptosis due to loss of innervation to LPS
Mydriasis due to loss of PNS fibres responsible for innervating sphincter papillae muscle

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15
Q

Which areas should be touched to assess the sensory component of the 3 branches of the trigeminal nerve?

A

Forehead(lateral aspect): ophthalmic (V1)
Cheek: maxillary (V2)
Lower jaw: mandibular branch (V3)

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16
Q

What do you inspect for before assessing the motor component of V3 of the trigeminal nerve?

A

Temporalis + Masseter muscles for wasting

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17
Q

How do you assess the motor component of V3 of the trigeminal nerve?

A

Palpate the masseter muscle + then temporalis bilaterally whilst patient clenches their teeth to assess + compare muscle bulk.
Ask patient to open their mouth whilst you apply resistance underneath the jaw to assess the lateral pterygoid muscles.

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18
Q

What are the 2 reflexes of the trigeminal nerve?

A

Jaw jerk

Corneal

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19
Q

What is the jaw jerk reflex?

A

Ask patient to open their mouth.
Place finger horizontally across their chin.
Tap finger gently with the tendon hammer.
Healthy: triggers a slight closure of the mouth.
UMN lesions: jaw may briskly move upwards causing the mouth to close completely.

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20
Q

What is the corneal reflex?

A

Gently touch edge of cornea using a wisp of cotton wool.
Healthy: direct + consensual blinking
Absence of a blinking response suggests pathology involving either the trigeminal or facial nerve.

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21
Q

What are the neural pathways involved in the corneal reflex?

A

Afferent: (nasociliary branch of) ophthalmic branch of CN V.
Efferent: temporal + zygomatic branches of CN VII.

22
Q

What is the facial nerve responsible for?

A

Motorinfo. to themuscles of facial expression+ stapedius muscle (involved in hearing).
Sensory: taste from the anterior 2/3 of the tongue.

23
Q

How do you assess the sensory component of the facial nerve?

A

Ask patient if they have noticed any recent changes in theirsense of taste.
If yes, test different tastes; salty, sweet, bitter, sour

24
Q

What might you ask a patient to assess the motor component of the facial nerve?

A

If they have noticed anychanges to their hearing(paralysis of stapedius muscle can result in hyperacusis).

25
Q

What do you inspect when assessing facial nerve function?

A

Forehead wrinkles
Nasolabial folds
Angles of the mouth

26
Q

What facial movements do you get the patient to perform when assessing the facial nerve?

A

Raised eyebrows:assesses frontalis (forehead wrinkling):
Closed eyes:assesses orbicular oculi (assess power)–
Blown out cheeks:assesses orbicularis oris (assess power)
Smiling:assesses levator anguli oris + zygomaticus major (look for asymmetry)
Pursed lips:assesses orbicularis oris + buccinator

27
Q

How does a facial nerve palsy caused by a LMN lesion present? What is the most common cause?

A

Weakness of all ipsilateral muscles of facial expression, due to the loss of innervation to all muscles on the affected side.
Most common cause = Bell’s palsy.

28
Q

How does a facial nerve palsy caused by a UMN lesion present? What is the most common cause?

A

Contralateral facial muscle weakness, however, upper facial muscles are partially spared because of bilateral cortical representation (resulting in forehead/ frontalis function being somewhat maintained).
Most common cause = stroke.

29
Q

How do UMN and LMN facial palsy’s differ?

A

LMN: Unilateral weakness of all ipsilateral facial muscles
UMN: unilateral weakness of contralateral facial muscles with forehead sparing

30
Q

What information is transmitted by the vestibulocochlear nerve?

A

Sensoryinfo. about sound + balance from the inner ear to the brain. No motor component.

31
Q

How do you perform a Gross hearing assessment?

A

Ask patient if they have noticed anychange in their hearingrecently.
Explain that you’re going to say3 words/ numbers+ you’d like them to repeat them back to you (2-syllable words or bi-digit numbers).
1 ear at a time (mask other ear. Whisper/ rub fingers together + check if they can hear)

32
Q

How do you perform Rinnes test?

A
  1. Place vibrating 512 Hz tuning fork firmly on the mastoid process to test bone conduction
  2. Confirm pt can hear vibrations + ask them to say when they can no longer hear it.
  3. When they no longer hear the sound, move the tuning fork in front of the external auditory meatus to test air conduction
  4. Ask if they can still hear the sound. If YES: air conduction is better than bone conduction (expected in a healthy individual =“Rinne’s positive” result)
33
Q

Where do you hold the tuning fork to assess bone or air conduction?

A

Mastoid process: Bone conduction- bone to nerves

Next to external auditory meatus: Air conduction- outer ear to middle ear to inner ear

34
Q

Describe the 3 possible results observed on Rinnes test?

A

Normal: air > bone conduction (Rinne’s +ve)
Sensorineural deafness:air conduction > bone conduction (Rinne’s +ve): due to both air + bone conduction being reduced equally. Must do Webers test or uninterpretable
Conductive deafness:bone conduction > air conduction (Rinne’s -ve)

35
Q

Where is the issue in conductive and sensorineural deafness?

A

Sensorineural: inner ear or vestibulocochlear nerve
Conductive: middle/ outer ear

36
Q

How do you perform Webers test?

A
  1. Tap 512Hz tuning fork + place non vibrating end in midline of forehead.
  2. Ask patient“Where do you hear the sound?”
  3. Assess in context with results of Rinne’s test
37
Q

Describe the 3 possible results observed on Webers test?

A

Normal:sound is heard equally in both ears.
Sensorineural deafness:sound is heard louder on the side of the intact ear.
Conductive deafness:sound is heard louder on the side of the affected ear.

38
Q

List 5 causes of conductive hearing loss

A 
Excessive ear wax
Otitis externa
Otitis media
Perforated tympanic membrane
Otosclerosis.
39
Q

List 5 causes of sensorineural hearing loss

A 
increasing age (presbycusis)
Excessive noise exposure
Genetic mutations
Viral infections (e.g. cytomegalovirus)
Ototoxic agents (e.g. gentamicin).
40
Q

What information is transmitted by the glossopharyngeal nerve?

A

motor: stylopharyngeusmusclewhich elevates the pharynxduring swallowing + speech.
Sensory:tastefrom theposterior 1/3of thetongue.

41
Q

What information is transmitted by the vagus nerve?

A

motor: severalmuscles of the mouthwhich are involved speech.
Sensory:back of thethroatwhich forms the afferent portion of thegagreflex.

42
Q

What do you ask the patient before assessing the glossopharyngeal and vagus nerves?

A

If any issues withswallowing, or changes to theirvoiceorcough.

43
Q

How do you asses the glossopharyngeal and vagus nerves?

A

Ask patient to say “ahh“:
Inspect palate + uvula which should elevate symmetrically, with uvula remaining midline.
Vagus nerve lesions: uvula deviates AWAY from affected side
Glossopharyngeal lesions cause asymmetrical elevation of the palate

44
Q

How would you assess the motor component of the vagus nerve?

A

Ask patient tocough:

CN X lesions can result in weak, non-explosive sounding bovine cough caused by an inability to close the glottis.

45
Q

What is the swallow assessment?

A

Swallow assessment
Ask patient to take asmall sip of water(~ 3 tsp’s) + observe themswallow.
Acoughor change to thequality of their voicesuggests an ineffective swallow caused by CN IX (afferent)/ CN X (efferent) pathology.

46
Q

What is the gag reflex?

A 
CN IX (afferent) + CNX (efferent). 
Stimulate posterior aspect of tongue + oropharynx which should trigger a gag reflex. Absence of a gag reflex = CN IX / CN X pathology.
47
Q

What information is transmitted by the accessory nerve?

A

Motor to Sternocleidomastoid + Trapezius

NO sensory component

48
Q

How do you assess accessory nerve function?

A
  1. Inspect for SCM or trapezius muscle wasting/ fasciculations.
  2. Ask pt to raise shoulders + resist you pushing downwards: trapezius (accessory nerve palsy results in weakness).
  3. Ask pt to turn their head left whilst you resist the movement + repeat with turning right: SCM (accessory nerve palsy results in weakness).
49
Q

Which direction assesses which sternocleidomastoid muscle?

A

Turn head left- right SCM responsible

Turn head right- left SCM responsible

50
Q

How do you assess the hypoglossal nerve?

A
  1. Ask pt to open their mouth + inspect tongue for wasting + fasciculations at rest (minor fasc can be normal).
  2. Ask pt toprotrudetheirtongue+observefor deviation(Tongue Towards = hypoglossal lesion).
  3. Place finger on pt’scheek+ ask them to push their tongue againstit. Repeat on each cheek to assess + compare power (weakness on side of lesion).
51
Q

What information is transmitted by the hypoglossal nerve?

A

Motortoextrinsicmusclesoftongue(except for palatoglossus which is innervated by CNX).
Nosensorycomponent.

52
Q

What is caused by a hypoglossal nerve palsy?

A

Atrophy of ipsilateral tongue + deviation of tongue towards the side of the lesion.
Functioning genioglossus muscle pushes tongue towards weak side

YR3: OSCE (6 decks)

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