Neurological Exam CN

Question 1

What might you see at a patient’s bedside?

Answer 1

Pupillary/eyelid abnormalities
Facial asymmetry
Gait abnormalities
Speech abnormalities
Walking, hearing, visual aids

Question 2

How do we test the olfactory nerve?

Answer 2

Ask have you noticed any changes to sense of smell.
If yes, what then?
Scented bottles test each nostril.

Question 3

When might the olfactory nerve be affected?

Answer 3

Head trauma
Parkinson's
COVID
Meningitis
Kallmann's
Brain tumour etc.

Question 4

How do we test the optic nerve?

Answer 4

Inspect pupils.
Visual acuity, neglect, fields
Pupillary light reflex
Accommodation reflex
Colour vision
Blind spot
Fundoscopy

Question 5

What do we inspect about pupils? (and what causes asymmetry)

Answer 5

Size
Shape
Symmetry - asymmetry caused by horners, oculomotor nerve palsy (down and out), drugs, holmer’s-adie syndrome (dilated pupil associated with knee problems post-infection)

Question 6

How do you know which pupil is abnormal?

Answer 6

Use a light, normal pupil will narrow.

Question 7

How do we assess visual acuity?

Answer 7

Snellen chart.
Ask if glasses or contacts - patients should wear them.
Consider using a pinhole, this will remove a refractory error and narrow diagnosis.

Question 8

How do we test optic nerve neglect/inattention?

Answer 8

Hold up hands on both sides of patient and then move fingers on one side and then the other. See if patients can see both. Then do both at the same time. Patient should be look at your face, you’re testing peripherals.
If they can’t see left side, it’s right sided issue in brain.

Question 9

How do you test visual defect? what defects?

Answer 9

Patient should cover left eye, you cover right eye. Move finger out of view at the top and ask them to say when they see it as you move down. Do same with bottom. Compare theirs to yours.

Hemianopia. Right upper quadrant (temporal lobe stroke or tumour), left hemianopia, bitemporal (optic chiasm), macular sparing (occipital cortex issue)

Question 10

How do we test pupillary light reflex?

Answer 10

Shine light in eye and observe constriction. Do again to check consensual.

Swinging light test - swing torch from left to right and to left again. As the torch swings to pupil, the pupil will dilate in pathology. Relative afferent pupillary defect - optic neuritis, linked to MS.

Question 11

What is the accommodation reflex?

Answer 11

Focus on an object close by after focussing on a distant object. The pupil will constrict and converge bilaterally.

Question 12

What do you use to text colour vision?

Answer 12

Ishihara plates.

Question 13

How do we test the oculomotor, trochlear and abducens nerves?

Answer 13

All motor.
Neutral position and follow finger for H test.
Ask for double vision or pain in sections. Nystagmus.
Oculomotor - all else
Trochlear - eyelid inferior rectus (down and out)
Abducens - lateral rectus (out)

Therefore, oculomotor palsy is down and out.

Question 14

What is the trigeminal nerve function?

Answer 14

Sensation, ophthalmic, maxillary, mandibular. Test by tapping on both sides, forehead, cheek and chin.
Motor, temporalis and masseter muscles.
Jaw jerk and corneal reflexes.

Question 15

How do you test the facial nerve?

Answer 15

Taste sensation to 2/3 anterior tongue - ask about any changes in taste and maybe give food.
Motor - muscles of facial expression.

Question 16

How do you know if it’s a LMN or UMN of the facial nerve?

Answer 16

LMN - unilateral weakness of all ipsilateral facial muscles including the forehead.
UMN - There’s a pathway that enables the forehead muscles, so not a complete ipsilateral weakness. Forehead sparing!!

Question 17

How do we test the vestibulocochlear nerve?

Answer 17

Cover one ear, rub fingers together by the other or whisper.

Rinne’s and weber’s test for sensorineural (nerve itself) and conductive (outer and middle ear) hearing loss.

Question 18

What is rinne’s test?

Answer 18

Vibrating against the bone (mastoid process), pull away and say can they hear in air. Air should be louder than bone conduction, but other way around if conductive issue.

Question 19

What is weber’s test?

Answer 19

Tuning fork above head. In normal they should hear it equally on both sides. Shouldn’t be louder in one ear. If rinne’s is negative, and this is positive, know this is sensorineural.

Question 20

We do glossopharyngeal and vagus together. How do we do this?

Answer 20

Inspect soft palate and uvula. It deviates away from the affected side. Reduced palate elevation on affected side.
Ask about swallowing difficulties, change in voice or cough.
Take sip of water, observe cough or change in voice quality.

Question 21

How do we test the accessory nerve?

Answer 21

Control SCM and trapezius.
Inspect muscle wasting, fasciculations.
Get patients to raise shoulders against resistance and turn head to the side. Do both action with and without.

Question 22

How do we test the hypoglossal nerve?

Answer 22

Inspect tongue, wasting and fasciculations.

Deviation is towards the affected side.