ECR Cranial Nerve and Eye Exam Flashcards
What does HPI include
General physical exam
Visual loss/changes
Diplopia (double vision)
Discharge
Erythema/redness
Eye pain
Related Hx of
Trauma Employment exposure Allergies Corrective lenses Medications
Common presentation of eye problems
vions loss (retina disease/stroke)
Visual distortion (macular degeneration, medication side effect
Itching/foreignbody sensation (foreign body, allergies)
Headache/dizziness (migrain/cerebllar disease)
Eye pain (glaucoa/ sinusitis)
Light sensitivity (coreanl abrasion/ meningities)
What eye chart is used for far vision
Snellen Chart
What eye chart is used for near vision
Rosenbaum card
What is the apporach to exam (3 parts)
- Vision assessment (always document vision PRIOR to and AFTEr exam)
- Inspectin ,palpation, and cranial nerve testing (external eye and ass. structures moving to more internal structures)
- Opthalmoscopic examination (internal eye)
What do you do for vision assessment?
Central Vision
- distance visual acuity
- near visual acuity
Visual fields
Color vision if warranted
What can DM, HTN, AIDs cause in ye?
Retinal changes
What can cause dry eye
Rheuatologic conditions
What can severe medication reaction/ Herpes Zoster cause
Red/eye conjunctivitis
Thyroid disease can cause
Proptosis/exopthalamos
Multiple sclerosis/ inc. intracranial pressure
Optic nerve changes/ body of eye; mc”
liver/biliary/pancreatic disease
scleral icterus
What is an Amsler Grid?
Used for central vision deficits like MACULAR DEGENERATION
stare at center dot to see if lines are croooked or bent
What does it mean if you see crooked lines or liens missing?
Macula degeneration!
What does the macula do?
macula of retina
How do you give external eye exam?
INspect surrounding areas
Eyebows for size, extension, hair texture
Orbial area for edema, exopthalamos (protudig troauma0
eyelids
lacrimal apparatus
How do you assess external pupil reaction ?
Direct
Consensual
Accomodation
What does it mean to do direct pupil exam
shine light to left eye–> left pupil constricts
Consensual pupil exam
Shind light to left eye, right pupil will contract
Accomodation
constriction of pupil and CHANGE OF SHAPE of lens to assist focusing on a lose object
Accomodation
constriction of pupil and CHANGE OF SHAPE of lens to assist focusing on a lose object
How do you test Extraocular muscles
muscle alignment/balance with penlight
movement using 6 cardinal fileds f gaze (H)
Conjugate (workign togehter) or dysconjugate
Assess convergence (follow fingers as you move it towards bridght of nose)
Observe for nystagmus
What is nystagmus
fine rhythmic oscillation of eyes
What is strabismus
misalignment of eyes
Which EOM for right and up
Right superior rectus muscle
Left inferior oblique
Which EOM for Left and up
Right inferior oblique
Left superior recturs
Which EOM for Right
Right lateral rectus
Left medial rectus
Which EOM for Left
Left lateral rectus
Right medial rectus
Which EOM right and down
Right inferior rectus
Left superior oblique
Which EOM for left and down
Right superior oblique
Left lateral rectus
What are components of the fundus?
Optic nerve/optic disc
Retina
Arteries
Veins
Macula and Fovea
What are common presentations of vision
change or loss of vision
Double vision (diplopia)
Facial weakness
difficulty speaking
Difficulty swallowing
Change or loss of hearing
Imbalance/vertigo
How do you test CN I
Olfactory
occlude and let patient semll something with one nostril at atime
NO noxious stimuli such as smelling salts or ammonia
How do you test CN II
Optic
Visual Acuity- eye chart
Visual Fields- Confrontation (2 wiggling fingers)
Visualization of the nerves (opthalamoscopic exam)
Pupillary response (afferent II, efferent III)
How do you test CN III
Oculumotor
MOtor: 4/6 muscles (inferior rectus, inferior olique, medial rectus, supieror rectus)
Convergence (ask pt to follow finger as u bring it to bridge of nose)
Elevate eyelid (levator palpebrae superioris m)
Pupillary light (direct and consensual)
Signs to look for if CN III is affected
Right CN III Palsy
Ptosis (eyelid drooping)
Eye is “down and out” at rest
Pupil more dilated than opposite eye
How to test CN IV and VI
IV- Trochlear
VI- Abducens
(LR6,SO4)3
CN IV- superior oblique; moves eye down adn in
CN VI- Lateral rectus; moves eye into abduction
Sings to look for if CN VI affected
right CN VI palsy
Excessive adduction at rest
Cannot adduct when gazing left
HOw to test for CN V Motor
Trigeminal
Motor: muscles of mastication- masseters, pterygoids, temporalis
Palpate
Assess Strength
How to test for CN V Sensory
Trigeminal
Sensory -sensation to face (sharp or cold?_ -3 divisions V1- Opthalamic V2- Maxiallary V3- Mandibular
Touch to face
Corneal Reflex
How do you test corneal reflex
CN V and VII
Use cotton and put to side of eye
Sensory input from surface of eye CN V
Motor response from CN VII (facial N)
In by V
Out by VII
How to test sensory for CN VII
Facial
Sensory:
Taste to anterior 2/3
Sesnation to small area behind ear and ear canal
How to test motor for CN VII
Facial
Muscles of facial expression Close eyes tightly Raise eyebrows Puff out cheeks Show me your teeth
Note asymetry, weakenss
How to test CN VIII (acoustic)
Acoustic (vestibulocochlear)
Semicicrular cnals/vestibular apparatus
balance
warm/cold caloric testing
special diagnostic maneuvers
*not clinically useufl for us yet_
How to test for CN VIII (cochlear)
Cochlea Hearing Acutiy (whisper test) Rinne Test Weber Test
If no hearing loss, is it louder in air or bone for Rinne test
Air > Bone
If no hearing loss, what is result of Weber test
hear it midline
If there is Sensorineural damage waht are results for Rinne and Weber
Rinee- Air > Bone
Weber : Louder in NORMAL EAR
If there is Conducton damage what are results for Rinne and Weber tests
Rinne test- Bone >A ir
Weber: Louder in IMPAIRED ear
CN IX
IX- Glossopharygeal
Sensory ; soft palate, pharynx, posterior tongue
Motor stylopharygenas
CN X
Motor: movement of the uvula and soft palate with phonation and gag
How to test CN IX and X
test together
let patient say “Ahhh”
Gag rellex
Swallow water
look for symmetric elevation of palate, midline uvula
Difficulty swallong ,poor phonation with speaking
How to test CN XI
Accessory
AKA: Spinal accessory nerve
Motor Trapezius (shrug shoulders)/ sternocleidomastoids (resist face)
assess strenght/test against resistance
How to est for CN XII
Hypoglossal
Motor- movement and protrusion of tongue
Assess position, movment and strength
Stick tongue straight out and move it side ot side
Look for fasciculations (involuntary muscle movement), atrophy, deviation from midline
CN IX
IX- Glossopharygeal
Sensory ; soft palate, pharynx, posterior tongue
Motor stylopharygenas
CN X
Motor: movement of the uvula and soft palate with phonation and gag
How to test CN IX and X
test together
let patient say “Ahhh”
Gag rellex
Swallow water
look for symmetric elevation of palate, midline uvula
Difficulty swallong ,poor phonation with speaking
How to test CN XI
Accessory
AKA: Spinal accessory nerve
Motor Trapezius (shrug shoulders)/ sternocleidomastoids (resist face)
assess strenght/test against resistance
How to est for CN XII
Hypoglossal
Motor- movement and protrusion of tongue
Assess position, movment and strength
Stick tongue straight out and move it side ot side
Look for fasciculations (involuntary muscle movement), atrophy, deviation from midline
