faq: how to examine the cranial nerves? plab 2 - part 2 of professional and linguistic assessments...

8/10/2019 FAQ: How to Examine the Cranial Nerves? PLAB 2 - Part 2 of Professional and Linguistic Assessments Board Exam …

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11/28/14, 10:AQ: How to examine the cranial nerves? PLAB 2 - Part 2 of Professi…l and Linguistic Assessments Board Exam Conducted by GMC, UK Forums

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FAQ: How to examine the cranial nerves?

how to examine the cranial nerves

I Olfactory

Smell

--------------------------------------------------------------------------------

Many examiners skip this cranial nerve during a comprehensive exam, but if the patient complains

of loss of smell (anosmia), it should be included in the physical exam.

Testing the sense of smell

Check each nostril for patency.Ask the patient to close their eyes.Take a peppermint, cinnamon stick, or fragrant soap and wave it below a nostril.Ask them to identify the smell testing each nostril separately.

Cranial Nerve I Deficits

--------------------------------------------------------------------------------

The olfactory nerve is part of our ability to smell. Loss of the sense of smell is called anosmia.Most patients with anosmia can still smell harsher smells (sweet and sour) but have difficulty withflavors like cinnamon and peppermint. Patients with anosmia often complain that they've lost theirsense of taste. Much of the pleasure derived from eating is due to smell, not taste (think of sniffing a glass of fine wine before drinking it). There are many causes for anosmia:

TraumaSurgeryMasses affecting the orbitofrontal region or cribiform plateDestruction of the neuroepithelium due to inflammation, as in chronic rhinitis or viral infection

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--------------------------------------------------------------------------------

II Optic

Vision

--------------------------------------------------------------------------------

Assessing Visual Acuity

Important: In cases of eye pain, injury, or visual loss, always check visual acuity before proceedingwith the rest of the exam or putting medications in your patient's eyes.

Allow the patient to use their glasses or contact lenses. You are interested in the patient's bestcorrected vision.Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a14-inch "reading" distance).Have the patient cover one eye at a time with an opaque card.Ask the patient to read progressively smaller letters until they can go no further.Record the smallest line the patient read successfully (20/20, 20/30, etc.)Repeat with the other eye and then both eyes combined.

Visual acuity is reported as a pair of numbers (e.g., 20/20) where the first number is how far thepatient is from the chart and the second number is the distance from which the "normal" eye canread a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a"normal" person can read from twice that distance.

DURING THE EXAM YOU CAN SHOW SOME NEWSPAPER TO THE PATIENT FOR READING. HOWEVER,YOU SHOULD BE ABLE TO EXPLAIN ALL THE ABOVE IF THE EXAMINER ASK FOR IT.

--------------------------------------------------------------------------------

III Oculomotor (Extraocular Muscle Control and Pupillary Reaction)

IV Trochlear (Extraocular Movements of Superior Oblique Muscle)

VI Abducens (Extraocular Movements of Lateral Rectus Muscle)

Observe for ptosis.Test Extraocular MovementsStand or sit 3 to 6 feet in front of the patient. Ask the patient to follow your finger with their eyeswithout moving their head. Check gaze in the six cardinal directions using a cross or "H" pattern.Pause during upward and lateral gaze to check for nystagmus.

Check convergence by moving your finger toward the bridge of the patient's nose.

--------------------------------------------------------------------------------

V Trigeminal (Motor)

Motor to the Muscles of Mastication

--------------------------------------------------------------------------------

Test Temporalis and Masseter Muscle Strength





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Ask the patient to open their mouth and clench their teeth.Palpate the temporalis and masseter muscles as they do this.

V: Trigeminal (Sensory)

Sensory to the Face

--------------------------------------------------------------------------------

Test the Three Divisions for Pain SensationExplain what you intend to do then ask the patient to close th

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Right CN3 Palsy: Patient's right eye is deviated laterally, there is ptosis of the lid, and the rightpupil (middle picture) is more dilated than the left. Note:

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(http://medicine.ucsd.edu/clinicalimg/eyes-cn6-palsy2.jpg)

Sixth Left Cranial Nerve Palsy: Left eye cannot move laterally beyond midline. In this case, causedby metastatic squamous cell cancer of the head and neck.

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Peripheral Left Cranial Nerve 7 Palsy: Picture on left demonstrates loss of wrinkles on left sideof forehead, inability to raise left eyebrow, and loss of left nasolabial fold. Picture on rightdemonstratesinability to close left eye or raise corner of mouth. In this case, the cranial nerve deficit was a

result ofmetastatic malignancy though Bell's Palsy would have a similar appearance.

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(http://medicine.ucsd.edu/clinicalimg/head-cn9palsey.jpg)

Cranial Nerve 9 Dysfunction: Patient has suffered stroke, causing loss of function of left CN 9. As aresult, uvulais pulled towards the normally functioning (ie right) side.

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Cranial Nerve 12 Dysfunction: Stroke has resulted in loss of function of left CN 12. When patientsticks tongue out, it therefore deviates to the left.

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Fri Jun 23, 2006 8:04 pm (8 years ago) #9 (modules.php?name=Forums&file=viewpost&p=277046

you are quite correct and coosceintious!

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Wed Jun 28, 2006 2:40 am (8 years ago) #10 (modules.php?name=Forums&file=viewpost&p=278757

Cools - I've done an OSCE Buster for this - the lower cranial nerves tend to be examined seperatelyfrom those doing the eyes.

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Wed Jul 05, 2006 3:37 am (8 years ago) #11 (modules.php?name=Forums&file=viewpost&p=281155

sepplabber wrote:

Right CN3 Palsy: Patient's right <a href="http://www.rxpgonline.com/tutorial/?q=eye&s=0">eye</a>is deviated laterally, there is ptosis of the lid, and the right pupil (middle picture) is more dilated than the left.Note:

In Diabetic mononeuropathy, Cr. III, IV a re involved and needed to be tested and pupillary function should be tested separately.

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Wed Jul 05, 2006 3:42 am (8 years ago) #12 (modules.php?name=Forums&file=viewpost&p=281158

Diabetic Cr. N III palsy

THIRD CRANIAL NERVE PALSIESPartial to complete weakness of the muscles innervated by the 3rd (oculomotor) nerve, resulting inptosis of the lid, mydriasis, and an outwardly turned eye during primary gaze.

When the patient attempts to turn the eye inward, it moves slowly only to the midline. Upwardand downward gaze is compromised in the affected eye. When downward gaze is attempted, thesuperior oblique muscle causes the eye to rotate inward.

The many causes of 3rd cranial nerve palsies include most major causes of CNS disease, so choiceof diagnostic tests should be based on the clinical features of the palsy. Intraorbital structurallesions producing external ophthalmoplegia and ocular myopathies should be distinguished fromcranial nerve disease. Exophthalmos or enophthalmos, a history of severe orbital trauma, or anobviously inflamed orbit suggests restrictive orbital disease, which may impair ocular motility.Myopathies are harder to diagnose but are suggested by a partial 3rd nerve palsy. The pupil isalways spared in myopathy.

Completely nonfunctional parasympathetic fibers (causing fixed dilated pupils) strongly suggestoculomotor nerve compression. The most common causes are aneurysm (especially of the posteriorcommunicating artery), trauma, and intracranial mass lesion. Oculomotor paralysis in anincreasingly unresponsive patient suggests transtentorial herniation and is a major emergency. If

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the pupil is completely spared but all other muscles innervated by the 3rd nerve are affected (eg,diabetic 3rd nerve paresis), the cause is likely to be an ischemic process of the oculomotor nerveor the midbrain; a demyelinating process is less likely. However, about 5% of posteriorcommunicating artery aneurysms causing oculomotor paralysis spare the pupil.

Third cranial nerve palsies are most indicative of serious disease when associated with severeheadache or altered consciousness.

A thorough neurologic examination with CT or MRI is performed. Lumbar puncture is reserved forsuspected subarachnoid hemorrhage when CT does not show blood. Cerebral angiography must beperformed if aneurysm causing subarachnoid hemorrhage is strongly suspected or when the pupil isclearly affected and no head trauma serious enough to fracture the skull has occurred.

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Sun Jul 09, 2006 1:09 am (8 years ago) #13 (modules.php?name=Forums&file=viewpost&p=282352

Bit long winded for a 5 minute OSCE station, but very thorough nonetheless.

Its not routine to CT/MRI everyone in the UK.

Diabetic MONOneuropathy affects one nerve, hence the MONO. Polyneuropathy affects more thanone nerve.

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Tue Jul 18, 2006 1:59 am (8 years ago) #14 (modules.php?name=Forums&file=viewpost&p=285648

thanx tez!

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20/20 vision 6/6 in metres

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Sat Oct 14, 2006 6:13 am (8 years ago) #16 (modules.php?name=Forums&file=viewpost&p=313513

Thanks very much for the details. I'd like to add one more thing for 2nd Cranial Nerve which is veryimportant i.e. Visual Fields.Regards

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Sat Oct 14, 2006 6:19 am (8 years ago) #17 (modules.php?name=Forums&file=viewpost&p=313515

It should be done ideally after the visual aquity test. Then to rule out any Scotoma, the test shouldbe done with Red Hat Pin, bringing to the central field with one eye closed and ask the patient "what colour the pin is". If the answer is pink it means there is scotoma. Later, the Pin should bemoved to horizontally towards temporal region, where it disappears. Again asking for colour to roleout Optic nerve damage.

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Wed Oct 25, 2006 9:48 am (8 years ago) #18 (modules.php?name=Forums&file=viewpost&p=316022

Allow the patient to use their glasses or contact lenses. You are interested in the patient's bestcorrected vision.Position the patient 20 feet in front of the Snellen eye chart .

Correction: it should be 10 feet !
















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Wed Nov 08, 2006 1:43 am (8 years ago) #19 (modules.php?name=Forums&file=viewpost&p=319809

hi guys.... this is an excellent step on how to examine CNs which is thought to be very hard..Agood approach is to know the nerves by heart so that it will be easy to perform the examination.

1) Olfactory is just assessing smell

2) Optic nerve:

-assess visual acuity, color vision and visual field- check direct and consensual light reflex

- then do a swinging test which is used to check for optic neuritis which is a sign of MS

-finally perform accomodation

3) Oculomoter, Trochlear, and Abducen are checked by assessing eye movement

4) Trigeminal nerve:

- sensory is checked by using a cotton and asking the patient to close their eyes while you assessthe divisions of the V nerve

- it is said by professors that it is important to ask if the touch feel the same because sometimesthey can feel it but one side is duller than the other

-motor is checked by muscle of masstication and temporal muscle on clenching the teeth

5) Facial nerve:

- ask the patient to show you his teeth, close his eyes and dont allow you to open it, and puff hischeeks

- leave raising the eyebrows for last because this test will distinguish if it is UMN or LMN

6) Vestibulocochlear nerve:

- it is checked by performing the Rinne AND Weber's test

7) Glossopharyngeal nerve and vagus:

- look at the soft palate and see if it is raised when the patient says AHHHH

- also look to see if the uvula is in the midline

-get for gag reflex

8) Accessory nerve:

- check the power of Sternocleidomastoid and trapezius muscle

9) Hypoglossal nerve:

- ask the patient to stick out his tongue

- look for deviation, wasting, or fasciculations.

I hope this is helpful for those who want to know how to examine CNs




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Location: U.K.

Sun Nov 26, 2006 10:12 pm (8 years ago) #20 (modules.php?name=Forums&file=viewpost&p=324742

Incomplete "nd nerve examination

I suppose, the Visual fields are part of Second which should be carried out. This OSCE was manytimes in exams where they wanted us to check the visual fiels and give them diagnosis such asHomonymous Hemianopia or Bitemporal.Regards

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