Case 6 – Tutor Guide

Week 1: Assessment of Cognitive Function

Week 2: Introduction to Examination of Cranial Nerves

Clinical Skills Teaching

Year 1 Medical Students MB BCh

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Contents

Introduction to workshop .............................................................................................. 3

Introduction to C21 Clinical Skills Curriculum ................................................................ 4

Providing feedback to students ..................................................................................... 5

Background – Case 6 ...................................................................................................... 6

Week 1 – Assessment of Cognitive Function .......................................................... 7

Suggested Workshop Structure – Guidance for Tutors .................................................. 8

Week 2 – Examination of the Cranial Nerves .......................................................... 9

Suggested Workshop Structure – Guidance for Tutors ................................................ 10

Appendix A – MoCA Test .............................................................................................. 11

Appendix B – MoCA Administration and Scoring Instructions .................................... 12

Appendix C - Guide to the Cranial Nerve Examination including examining eyes/vision

and ears/hearing .......................................................................................................... 16

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Introduction to workshop Welcome! Thank you for agreeing to help with this teaching.

These workshops occurs in the sixth case of Year 1. Prior to this case students have been introduced and had limited opportunities to practice the skills required for history taking. They have also been introduced to the following system based physical examinations and procedural skills:

Physical Examinations Procedural Skills

Musculoskeletal System – Knees & GALs Intramuscular & Subcutaneous Injections

Gastrointestinal System Urinalysis, Pregnancy Tests & Swab Taking

Cardiovascular System Performing ECGs

Respiratory System Respiratory Function Tests

The focus for all these sessions is to introduce the students to the particular tasks and give them an opportunity to practice.

The students will have further opportunities to practice most of these skills in timetabled sessions in Year 2. They also can attend the Self Directed Learning area in the Clinical Skills Centre to practice the skills further.

This teaching session is delivered in parallel across the four centres used for year 1 and Year 2 clinical skills teaching – Merthyr, Newport, Bridgend and Cardiff.

Each centre may adapt the session to suit their own practical arrangements but it is important that all students get the same core teaching.

This teaching session is formatively assessed – this means that attendance is compulsory and students should get feedback whenever possible on their performance. If tutors are concerned that a student is not engaging with the session or is performing particularly poorly please inform the undergraduate manager or Paul Kinnersley (see below).

There is a formal assessment of the students’ clinical skills including their history and examination skills at the end of Year 2.

Students have access through the Learning Resource Platform (Blackboard) to a ‘Guide to examining the cranial nerves, eyes and ears’. This guide should be read in conjunction with this teaching plan.

If you have questions about this teaching please contact Paul Kinnersley, Director of Clinical Skills, kinnersley@cf.ac.uk or Sian Williams, Lead for Procedural skills teaching WilliamsSE17@cf.ac.uk

Thank you again for your participation The Clinical Skills and Simulation Team

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Introduction to C21 Clinical Skills Curriculum

The aim of C21 early clinical learning is that students learn to integrate their clinical, basic, behavioural and social sciences whilst exploring patients’ experiences of illness. It also seeks to help the student gain competence in history taking and in conducting physical examinations, whilst learning clinical reasoning and decision making skills. Good consultation skills lie at the heart of healthcare and as such students will be taught how to consult effectively from the beginning of the C21 course. Core skills are essential and may be learnt and developed through experiential learning, in order that students become equipped with a core set of skills to enable them to progress and master more complex consultations during their careers.

Through meeting real patients from the earliest stages of their undergraduate course and learning about the experiences of illness, we want students to develop a patient-centred approach to clinical practice and develop professional attitudes towards patients and colleagues.

The process of learning clinical skills:

In Phase 1 B students spend 1 day each week on Community Based Learning Placements (half the day) and learning clinical skills (half the day). During their Community Based Learning placements, students will rotate through a range of activities – visiting patients in their own home, visiting community physio clinics and see patients in GP surgeries so they meet real patients in a variety of settings which will ‘bring to life’ and contextualise their case-based learning and give them the opportunity to witness the effect of social environment on health and healthcare. They will also develop and learn transferable skills and informed professional attitudes, through contact with a multi-professional cohort of teachers.

Clinical skills teaching in Phase 1B consists of seven history and examination teaching sessions, three procedural teaching sessions, one session on assessing respiratory function and one on examining the eyes and ears.

Please note – the clinical skills teaching session are matched with Community based teaching sessions (students will do clinical skills in the morning and Community based learning in the afternoon or vice versa). There is overlap between these teaching sessions – see individual lesson plans – in the afternoon sessions please remember to ask students what they have done already in the morning so we can build on their prior learning.

Practise clinical skills in ‘real-life’

clinical setting

Practise clinical skills in controlled

clinical setting

Learn clinical skill in class room

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Providing feedback to students A key part of Clinical Skills teaching is providing feedback to students on their performance. To help learning, feedback needs to be objective and aligned with what the student is trying to achieve (their learning agenda or their individual learning needs). Early in the course students find it difficult to identify individual learning needs because they simply feel they need to learn everything – however it can still be helpful to start with this approach.

There are generally 2 agendas for feedback in the workshops and the tutor should seek to incorporate both:

What do the students feel they want/need to learn?

What do we want to teach them?

Where possible, feedback should be:

S - Specific, Significant, Stretching M - Measurable, Meaningful, Motivational A - Agreed upon, Attainable, Achievable, Acceptable, Action-oriented R - Realistic, Relevant, Reasonable, Rewarding, Results-oriented T - Time-based, Timely, Tangible, Trackable

The way in which we give feedback can directly influence how the students respond to the learning experience, and so if we are to nurture them, we need to do this in a supportive, safe fashion.

Review learner’s original agenda and encourage self-feedback from student

Provide constructive, timely feedback based on observations from tutor

Encourage supportive input from other students to solve problems

Re rehearsal of new skills, either by the individual, or by subsequent students incorporating lessons learnt earlier in workshop through observation of their peers.

– Ask the student ‘How did that go?’ – Link this to the students own agenda – Ask the student ‘What could be improved?’ – Open discussion to the other things for them to improve/ focus upon

Struggling students

It is important that students who struggle with their clinical skills for whatever reason are identified early. If a student in your group raises concerns, please take a little time at the end of the session to clarify how the student felt the session went. Some may just be nervous or unfamiliar with the teaching methods used. However, we routinely offer, all students who need them, remedial sessions – but we want to target these at those who need them most and need your help to identify these students. Tutors are therefore encouraged to be proactive about identifying students who they feel might benefit from such extra support, and pass their details to Jo Sloan (sloanjm@cf.ac.uk), so that students can be contacted at the appropriate time. If you have major concerns about a student’s behaviour please discuss your concerns with them if appropriate AND send a report to Paul Kinnersley (kinnersley@cf.ac.uk).

All students will be informed that you may raise your concerns with them and that this is meant to be helpful rather than to be seen as criticism.

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Background – Case 6

Brief summary (taken from the Case Facilitator’s guide)

‘The case, cognitive decline, will provide students with opportunities to pursue a guided inquiry into how the brain works and the structure and function of different regions of the brain. Promoting cognitive health and healthy ageing is becoming increasingly important, given the current global increase in the prevalence of dementia and associated implications for individuals and society. An older person becoming forgetful is the stimulus to explore this topic. Students will examine the determinants of cognitive health across the life course and explore how the brain is susceptible to diseases such as dementia. Students will also have the opportunity to develop insight into different scientific methods to research the brain and cognitive function. History taking and examination of the central nervous system and assessment of the mental state will be introduced during this case. The clinical method and community sessions for this case will allow the development of communication skills and provide students with opportunities to explore the social inclusion of older people particularly those with cognitive impairment. Understanding of the principles of autonomy and mental capacity will be developed through ethical debate in small groups. Diagnostic methods will be developed through the demonstration of neuropsychological tests and administration of brief cognitive screening tests.’

In the case fortnight students will get plenaries on Hearing, the functional anatomy of the inner ear, Aging and Cognition and the mental capacity act.

The Higher Level Clinical Skills Learning Outcomes for the Case are:

H1. Assess cognitive function using brief cognitive screening tests including administration of MoCA (Week 1)

H2. Demonstrate how communication can be improved in consultations with patients who have hearing difficulty (Week 1)

H3. Perform a focussed examination of the cranial nerves including the use of an auroscope and ophthalmoscope (Week 2)

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Week 1 – Assessment of Cognitive Function

Overall Session Aim (3 Hours)

Students will learn the skills required to assess a person’s cognitive function with a particular focus on using the Montreal Cognitive Assessment (MoCA). They should also develop their understanding of the impact of cognitive impairment both on the individual and the family and consider how any negative impacts can be reduced.

Intended learning outcomes

By the end of this workshop the students should be able to:

Differentiate between confusion, delirium and dementia

Describe the common symptoms patients with cognitive impairment and sensory deficits present with

Demonstrate how to assess a patient’s higher intellectual function and to detect cognitive impairment using brief screening tests such as the Montreal Cognitive Assessment

Discuss how impairment of cognition, hearing and vision can impact on social functioning and how social circumstances can mediate or exacerbate these impairments

Practice undertaking a MOCA on a fellow student

Consider how impaired hearing and vision can impact on the social functioning of patients

Discuss the particular challenges when consulting with patients with cognitive impairment and sensory deficits

Describe methods to help patients with impaired hearing and vision so as to reduce the impact on social functioning

Describe how other impairments (mental or physical) impact on the overall quality of life of patients

Consider the communication skills needed to consult with patients with cognitive impairment and their families

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Suggested Workshop Structure – Guidance for Tutors

Each centre may adapt the session to suit their own practical arrangements but it is important that all students get the core teaching addressing the learning outcomes above.

Assessment of Cognitive Function

Resources

One tutor One room Three video clips (1 MoCA administered well to fit 80 year old; 2 to 75 year old with moderate Alzheimer’s dementia; and 3 very badly to 80 year old), powerpoint presentation, practice MOCAs (and instructions) and hearing aid leaflets provided by Prof Tony Bayer

Time Activity

30 mins Introduction to session – Common symptoms of cognitive impairment

60 mins Brief introduction to MoCA Watch video of MoCA administered well to fit 80 year old & discuss. In pairs perform MoCA assessment on each other.

20 mins Tea break

30 mins Watch video of MoCA administered well to dementia patient & discuss (followed, if time available, to show some of video of MoCA administered badly).

30 mins Consider impact of impaired vision/hearing/ education/culture/language/ use of interpreters Hearing aids –practical demo & leaflet Visual problems (small print/illumination)

10 mins Summary/quiz – cognitive impairment and its assessment/impaired vision and hearing/skills needed for good communication/factors impacting on QoL

Additional Resources

MoCA demonstrations https://www.youtube.com/watch?v=TZ_zDSxO4Bk https://www.youtube.com/watch?v=ryf8SG0NQLQ - administration https://www.youtube.com/watch?v=y0KFQ7Lgf-w – scoring

MoCA Test – See Appendix A MoCA Administration and Scoring Instructions – See Appendix B Suggestions on how to communicate with patients with dementia

http://geekymedics.com/2014/12/19/patient-dementia-communication-tips/ http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1211&pageNumber=2

Hearing http://www.nhs.uk/Livewell/hearing-problems/Pages/hearing-problems.aspx

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Week 2 – Examination of the Cranial Nerves Overall Session Aim (3 Hours)

Students will learn the skills required to examine the cranial nerves with particular emphasis on performing an Ophthalmological examination and examining the ears and hearing.

Students can practice these skills by examining each other – assuming they consent to this. Alternatively suitable patients can be used.

Students will have further opportunities in Year 2 to practise these skills.

Intended learning outcomes

By the end of this workshop the students should be able to:

Describe the functions of the Cranial Nerves

Identify the common symptoms patients with Cranial Nerve lesions may present with

Practice and perform the examination of the Cranial Nerves

Practice and perform examination of patient’s vision (visual acuity, visual fields and eye

movements) and fundi including using an ophthalmoscope

Practice and perform examination of patient’s ears and hearing including using an otoscope and

performing Rinne’s and Weber’s tests.

Practice and perform examination of the mouth

Practice and perform examination of the neck

Recognise some common abnormalities of the ears and eyes

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Suggested Workshop Structure – Guidance for Tutors

Each centre may adapt the session to suit their own practical arrangements but it is important that all students get the core teaching addressing the learning outcomes above.

Introduction to Examination of Cranial Nerves

Resources If 15 students 2 tutors If 30 students 4 tutors Ophthalmoscopes/Otoscopes Snellen chart Pen torch Tongue depressors Tuning forks (512 hz) Students can examine each other but if anatomical models available this may be helpful

Time Activity

30 mins Introduction to session – function of cranial nerves and what abnormalities they are aware of

90 mins Practice examination – students examining each other Examining the eye and vision and relevant cranial nerves (including fundoscopy and ocular movement) Examining the Ear and hearing (VIII cranial nerve) Examining the mouth and neck Cranial nerves V - VII Cranial nerves IX - XII

20 mins Tea break

40 mins Discussion of some common abnormalities using video clips and photographs

Additional Resources

Geeky Medics Guide - Examining the Neck: http://geekymedics.com/neck-lump-examination-osce-guide/

Guide to the Cranial Nerve Examination including examining eyes/vision, ears/hearing, mouth and

neck – See Appendix C

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Appendix A – MoCA Test

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Appendix B – MoCA Administration and Scoring Instructions

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Appendix C - Guide to the Cranial Nerve Examination including examining eyes/vision and ears/hearing

A copy of this is available to students on Learning Central

Please note: as with other examinations, different clinicians will perform these examinations in slightly different ways – and different resources (Macleod’s Clinical Examination, www.geekymedics.com etc) may describe the examination slightly differently. Students need to establish their own routine for performing these examination and this Guide is intended to help them do this. Students do NOT fail ISCEs/OSCEs if they do the examination slightly differently to as described here. As with any examination, a careful history is needed before the examination as this will strongly guide you as to what examination to perform and what you may find! Feedback is welcome – please send to Paul Kinnersley (kinnersley@cf.ac.uk) This guide was written with the help of Dr Clinton Mitchell, Dr Farid Girgis, Dr Alan Stone and colleagues and Dr Sejal Bhatt At the start of every examination Clean hands Introduce yourself to the patient Explain what you are going to do, check patient consents and check if patient in any pain Expose the patient appropriately preserving dignity

Outline of Cranial Nerve Examination Observe the patient’s general condition – aids (e.g., frame, wheelchair) at the bedside, reading glasses, hearing aid. Look for muscle wasting (temporalis), ptosis (drooping eyelid), drooping mouth, asymmetric facial creases. Patient sitting comfortably. Usually examine at the same height as the patient so examiner should sit also (or stand with patient sitting on plinth/couch).

Cranial Nerve Examination

I Olfactory Assess patency of each nostril. Enquire about changes in sense of smell.

II Optic Visual acuity (Snellen chart) and ask patient if recent change Visual fields – each eye separately Pupillary reflexes – light and accommodation (remember to check the other eye) and the swinging light test; observe direct reflex – constriction of pupil in eye you shine light into and consensual reflex –constriction of other pupil Ophthalmoscopy - For more detail see below

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III/IV/VI Oculomotor Trochlear Abducens

Inspect eyelids and pupils – for symmetry, reactions to light and accommodation Eye movements – ask patient to follow finger – move in H shape, ask if see double at any time Check for nystagmus – flickering movements of eyes – hold finger at approximately 30 degrees of lateral/vertical vision (at the extremes of gaze physiological nystagmus is seen) For more detail see below

V Trigeminal Sensory – cotton wool touch over 3 divisions – ask patient to close eyes, check for symmetry Motor – clench teeth; open mouth against resistance Consider corneal reflex/jaw jerk

VII Facial Observe face for asymmetry/ involuntary movements Wrinkle forehead/Bare teeth/screw eyes shut tight/blow out cheeks Remember upper half of face innervated by both cerebral hemispheres so if upper motor neurone lesion can still wrinkle forehead

VIII Vestibulocochlear Ask patient if any recent change in hearing Test hearing by rubbing fingers together or whispering Otoscopy Rinne’s test – place 512 Hz tuning fork on mastoid process then move to in front of ear – ask which is louder? Air conduction better than bone conduction is normal. If not, then conductive hearing loss Weber’s test – place tuning fork middle of forehead – should 'hear’ vibration equally in both ears; if lateralises can suggest conductive hearing loss in louder ear or sensorineural loss in other ear For more detail see below

IX/X Glosopharyngeal Vagus

Unusual to have abnormalities and difficult to test Observe for palatal elevation with “ahh”. The uvula will be pulled away from the affected side (opposite of tongue).

XI Accessory Shrug shoulders (trapezius); turn chin against resistance (sternocleidomastoid)

XII Hypoglossal Examine tongue for wasting/fasciculation (flickering movements) Ask patient to stick out tongue – if deviates suggests lesion on that side

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Ophthalmology Ask patient if they wear glasses or contact lenses Ask if any recent change in vision or any other eye symptoms General

Orbits Any obvious swellings around the eyes or bulging of the eyes Eyelids Any swelling, drooping or lumps Sclera/conjunctiva Pallor? Jaundice? Infection? Cornea Opacity? Arcus?

Visual acuity

Sit/stand the patient at standard distance – 6m for standard chart, 3m for 3m chart

Test each eye separately asking patient to cover other eye

Test first with glasses on – ‘best corrected’ then with pinhole as well ‘best corrected and pinhole’

Ask patient to read letters on chart; lowest full correct line is their visual acuity

Repeat with glasses – or pinhole correction

Record visual acuity (with/without glasses) as a fraction – numerator distance from chart (6 with standard chart) denominator line reached on chart – so 6/6, 6/12 and so on. This means patient can read at 6 m what a person with normal vision can read at X where X is the line the patient can read.

Near vision can be tested using an appropriate chart – again one eye at a time.

Visual Fields

Patient and examiner sit facing each other about 1 m apart

Each covers opposing eye (eg patient left, examiner right) and stare into each other’s open eye

Examiner brings a hand (positioned halfway between self and patient) from the periphery into the field of vision successively in each quadrant until the patient detects the movement.

Using Ophthalmoscope

Darken room/ideally sit patient on raised chair/couch so that can look into eyes without excessive bending

Switch on ophthalmoscope and check large bright white light (move switches on back of head if not)

Set focussing wheel to zero – unless you know you need some other number because of your own eyes

Remove patient’s glasses – optional to remove own glasses

Warn patient that you are going to shine bright light into eye

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Ask the patient to look at distant object straight ahead and to keep looking into the distance even if your head gets in their way

For patient’s right eye, hold ophthalmoscope in right hand and use your right eye; for left eye, left hand and your left eye (if possible).

Place thumb on patient’s eyebrow – to help keep head still and act as buffer

At arm’s length distance from patient, look at pupil – should see red reflex.

Now gradually move in towards patient until almost touching them, keeping looking through lens to focus on retina – rotating focussing wheel a few clicks if necessary (don’t go too far too fast)

Locate the optic disc – if can’t find disc follow major blood vessels until you do find it – the Vs of branching vessels point back towards the disc:

Look at the disc for pallor (atrophy), a swollen ill-defined edge (papilloedema), a large cup (cupping is a cup: disc ratio equal to or greater than 1:2) and at the vessels of the disc.

Examine the peripheral fundus. Each quadrant should be examined in turn. Do this either by asking the patient to look at each of the four quadrants in turn, or by moving your direction of gaze into each of the four quadrants. Look at the vessels, and for the presence of exudates, haemorrhages, or abnormal pigmentation of the fundus.

To look at the macula, focus on the disc with the patient focusing on a distant object in front of them. Then ask the patient to look into the light of the ophthalmoscope and you will be looking at the macular region and fovea. If all you can see is the reflected light, then reduce the intensity of the illumination.

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Examination of the Ear and Hearing

Ask patient if any recent change in hearing or any other ear symptoms General

Pinna Congenital abnormalities, shape, skin disorders – remember to look and feel behind the ears and to check both sides

Opening of external auditory meatus Look for discharge/inflammation Using the otoscope

Explain procedure to patient

Place clean speculum on otoscope

For right ear hold otoscope in right hand and vice versa for left ear, light grip – to ensure gentle movements

Gently pull pinna upwards and backwards

Place tip of speculum in the external auditory meatus under direct vision

Start looking through the otoscope and gently advance it

The tympanic membrane is translucent and with a light reflex just below the malleolus

Diagnosing hearing loss

A diagnosis between the chief types of hearing loss can be made by means of a tuning fork, using a 512 Hertz fork gently sounded. Rinnes test and Webers test are done to differentiate between a conductive (middle and outer ear causes) and a sensorineural deafness (caused by damage to the cochlea or to the 8th nerve – or its central connections). These tests are always done together. The Rinnes test is done first.

Rinne Test:

The tuning fork is presented with the tines at the external auditory meatus and then the base is pressed firmly on the mastoid process. The patient is asked which is heard the louder. If the tuning fork is heard louder at the external auditory meatus then this is normal and the patient is Rinne positive on that side (the ossicular chain is an amplifier). If the bone conduction through the mastoid process is heard louder then the patient is Rinne negative, ie abnormal. Causes for a negative Rinne include a build up of wax or chronic secretory otitis media.

Both ears need to be examined in a similar way to exclude the possibility of a false positive Rinne when the patient has a profound conductive deafness on the side being examined. In

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this case the sound will be conducted to the other side of the head where the remaining sensorineural apparatus is intact. The use of a complimentary Weber’s Test should confirm the above findings and should help discriminate between a true Rinnes negative and a false Rinnes negative.

Weber’s Test:

A tuning fork should be placed firmly on the skull vertex or at the forehead in the midline and the patient asked in which ear the sound is best heard. The back of the patient’s head should be supported by the examiner’s other hand. In a conductive hearing loss of one ear the patient can be expected to point to the ear in which there is a conductive hearing loss. A simple way to demonstrate and understand Weber’s Test is to place a finger occluding one ear (mimicking a conductive deafness) and with a tuning fork sounded over the vertex of the skull. Sound should be conducted to the occluded ear. If both ears are affected by a conductive hearing loss the tuning fork would be heard in the ear which is the more affected.

In sensorineural hearing loss the sound would be conveyed to the ear with the better functioning sensorineural apparatus. Acoustic neuroma is an example of a condition causing profound sensorineural deafness.

Measurement of Hearing Loss

The simplest and easiest procedure to measure hearing loss is to ascertain whether a patient can hear a whisper in one ear when the other ear is covered.

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Examining the mouth

For this you need a good light source – this can be a hand held torch but head torches or mirrors leave your hands free

Inspection

Look at the patient’s whole face and neck looking for any swellings, lumps, asymmetry, bruising or other abnormalities

Look more closely at the patient’s lips and then start to inspect the gums and teeth. General state of gums and teeth indicate general health

Ask the patient to remove dentures if warn and appropriate to do so

Look for areas of ulceration, inflammation, discolouration, lumps and swellings include inspection of the hard palate. White plaques are typically seen in the mouth with candida infection

Look particularly at the tongue and then ask patient to touch roof of mouth with tongue so can inspect floor of mouth

Look at back of mouth and oropharynx – again looking for ulceration, inflammation, discolouration, lumps and swellings. Ask patient to say ‘Aagh’. If necessary use tongue depressor gently – some patients find this uncomfortable. Inspect the tonsils – may be difficult to see in adults.

When patient says ‘Aagh’ uvula should rise up – note any deviation to one side – IX nerve palsy, infection, tumour

Ask patient to stick out tongue and point to left – inspect right hand edge; then point to right and inspect left hand edge

If any lumps noted on inspection, put on gloves and gently palpate

Examining the neck Inspection

With the patient sitting down and with head in neutral position (looking straight ahead) and with adequate exposure – inspect neck from front and sides. Look for lumps, swelling, discolouration, rashes

Palpation

Stand behind seated patient

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Work systematically using tips of fingers starting with the submandibular region – feeling for lymph nodes, then move down the anterior triangle also feeling for any mid line swellings, then feel posterior triangle, behind the ears – post auricular lymph nodes and then supraclavicular fossae

If lumps or swelling found consider its position and whether it is tender? Soft/hard? Fixed to skin or underlying structures? Pulsatile?

For midline swellings ask patient to swallow – thyroid or thyroglossal cyst will move. Ask patient to stick out tongue – thyroglossal cyst will rise

If appropriate inspect JVP