Cranial Nerves Flashcards
Summarise general inspection?
- General appearance?
- Head position?
- Obvious facial asymmetries?
- Position of eyes?
- Abnormality of speech or voice?
- Signs around bed? (Hearing aid, glasses etc.)
Summarise I - Olfactory nerve?
Ask patient: have you noticed any change in sense of smell?
With eyes closed, ask patient to identify various distinctive scents.
Summarise II - Optic Nerve?
Very Very Big
- Visual acuity - Patient stands 6m from Snellen chart. Ask patient to cover one eye and read lowest line they can. VA = chart distance/lowest line read. Repeat with other eye.
- Visual fields - Ask patient to cover one eye with hand, you mirror the patient. Ask patient to tell you when they can see your finger. Ensure arm is equidistant between you and patient. Slowly bring finger inwards towards centre of visual field until they see it. Repeat process for each quadrant and do other eye.
- Blind spot - Move pin horizontally and vertically and ask patient to tell you when they can/can’t see it.
Summarise Optic Nerve II?
Fat People Are Sexy
- Fundoscopy - say you would do this.
- Pupils - Direct relfex - shine torch into eye - pupillary constriction in that eye. Consensual reflex - shine torch into eye - look for constriction in opposite eye.
- Accommodation - Ask patient to focus on distant point, then swtich focus to your finger 15cm in front of eyes. Should be convergence and constriction bilaterally.
- Sensory inattention - Ask patient to focus on face. Fingers in periphery, they say which one is wiggling.
Summarise III, IV and VI?
- Ask patient to keep head still and follow finger with their eyes.
- Move finger through an H shape.
Ask patient to report any double vision and observe for restriction of eye movement and note any nystagmus.
Summarise V?
Sensory
- Assess light touch and pin-prick sensation in three areas supplied by V
- Forehead (V1)
- Cheek (V2)
- Jaw (V3)
Motor
- Ask patient to clench their teeth and feel for bulk of temporalis and masseter laterally.
- Ask patient to open mouth and not let you close it when you apply pressure (Jaw will deviate to side of lesion).
Reflex
- Jaw jerk - ask patient to open mouth loosely. Place finger horizontally across chin and tap finger with tendon hammer.
Normal = slight closure of jaw.
Abnormal = brisk, complete closure of jaw = UMN lesion.
- Corneal reflex - mention this.
Summarise VII?
Inspection
- Pay attention to forehead winkles, nasolabial folds and angles of the mouth.
Ask patient to perform following movements.
- Raised eyebrows
- Scrunched up eyes (assess power)
- Blow out cheeks (assess power)
- Baring teeth
- Purse lips
Other things
- Inspect external auditory meatus (herpes zoster)
- Any hearing changes? (stapedius)
- Any taste changes? (anterior 2/3 of tongue).
Summarise VIII?
Gross hearing testing
- Assess each ear individually. Whisper a number in the ear (66/99) whilst masking other ear by creating white noise. Ask patient to repeat number back to you.
Rinne’s test
- Tap tuning fork and place onto mastoid -bone conduction. When patient can no longer hear it, hold it next to ear = air conduction. Ask patient if they can now hear tuning fork.
Neural deafness = air > bone
Conductive deafness = bone > air
Weber’s test
- Tap tuning fork and place in centre of patient’s forehead. Ask if louder on particular side.
- Normal = equal
- Neural deafness = louder on intact ear
- Conductive = louder on affected ear.
Summarise IX and X?
- Assess soft palate and uvula. Symmetry - note any deviation. Ask patient to say ahhhh.
- Gag reflex - menion it.
- Ask patient to cough - damage to nerves can result in ‘bovine’ cough.
- Swallow - ask patient to take a sip of water - note any coughing/delayed swallow.
Summarise XI?
Ask patient to shrug shoulders and resist you pushing down - trapezius.
Ask patient to turn head and resist you pushing it to the other - sternocleidomastoid.
- Note any unilateral/bilateral weakness present.
Summarise XII?
- Inspect for wasting and fasciculation at rest.
- Ask patient to protrude tongue - any deviation?
To conclude?
Thank patient
Wash hands
Summarise findings
End pieces:
- Perform further testing of any nerves that had abnormal results
- Carry out full neurological exam of upper/lower limbs
- Perform further imaging if indicated - MRI/CT head.
