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Cranial nerves examination - OSCE notes

This tutorial cover the most important things regarding the examination of cranial nerves. this tutorial is OSCE oriented and for more details see the refrences regarding the clinical examination.

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Cranial nerves examination - OSCE notes

  1. 1. Notes on Cranial nerve examination
  2. 2. Olfactory nerve examination • Ask patient to close one nostril and to expirate to see f there is foreign body. • Closing one nostril, ask patient to know the smell on the other. • Repeat for the other nostril.
  3. 3. Optic nerve examination • 5 things to examine in optic nerve • Visual acuity • Visual field • Color vision • Pupillary reflex (2 is afferent, 3 is efferent) • Accomodation reflex (2 is afferent, 3 is efferent) • Ophthalmoscopic examination
  4. 4. Visual acuity • Snellen's chart. • Evaluation of patient with poor vision.
  5. 5. Visual field • Sensory Inattention • Central visual field • Examination of blind spot • Peripheral visual field examination
  6. 6. CNs III, IV, VI Prime position H test Pupillary reaction Ptosis Nystagmus Direct reaction reflex Proptosis Eye limitation Indirect reaction reflex Anisocoria (pupillary inequality) Diplopia Accomodation reflex
  7. 7. Notes • Unilateral due to CN III palsy or Horner's syndrome • mydriasis is pupillary enlargement, meiosis is constriction.
  8. 8. Oculomotor III, trochlear IV and abducent VI nerve exam • H test • In abducent paralysis, eye on medial side on rest and can not go laterally. • In trochlear nerve injury, eye on rest laterally and above which can not on movement go medially and below, and worsen when head laterally flexed to normal area.
  9. 9. Lesion and test of Trochlear IV nerve
  10. 10. Oculomotor nerve III palsy
  11. 11. Abducent nerve VI palsy
  12. 12. Trigeminal nerve examination 1. Test for sensory functions • Examine the 3 divisions of V nerve bilaterally. 2. Test for motor function • Muscle wasting (temporalis, masseter) • Clench teethes to palpate masseter • Open jaw and see deviation • Open mouth against resistance 3. Test for reflexes 1. Corneal reflexes (5 is afferent, 7 is efferent) 2. Jaw jerk
  13. 13. 5+12 = 17 • Damage to V cranial nerve cause jaw to deviate to the affected side (As the 12th cranial nerve)
  14. 14. Jaw jerk • Normally, slide closure or no reaction at all. • In pseudobulbar palsy (UMNL), this reflex is exaggerated. • This will lead to clenching of teeth.
  15. 15. Fascial nerve VII Examination • Weather it is bilateral, unilateral or upper MNL or LMNL and ipsilateral or contralateral. • 5 things • Test sensation in anterior 2 /3 of mouth • raise your eyebrows • Close your eyes • Nasolabial fold • Blowing air wheezing ‫صفير‬ • Corneal reflex (5 is afferent, 7 is efferent) • Hyperacusis
  16. 16. How to know if this is UMNL or LMNL in patient with fascial nerve VII exam? • Bells phenomena present and Frontal wrinkles – absent in patient with LMNL on the ipsilateral side. • Both mouth deviation to normal side and nasolabial fold absent are found in UMNL and LMNL. • Bilateral lower motor neuron lesion will have absent of both forehead wrinkles with absent nasolabial fold on both side that mimic normal persons.
  17. 17. • LESION A ?!!! • weakness of lower left half of face • Contralateral ! • UMNL • LESION B ?!! • complete weakness of left half of the face • Ipsilateral • LMNL UMNL Vs. LMNL of fascial nerve
  18. 18. Most common cause .... • Most common cause of upper motor neuron lesions is multiple sclerosis (MS). • Most common cause of lower motor neuron lesions is poliomyelitis.
  19. 19. Glossopharyngeal IX and vagus X nerves examination • Speach (dysarthria and dysphonia) • Swallow • Cough • Air escape from nose • In unilaterla X nerve damage, uvula will deviated to normal side (like VII nerve) the rule of 10 and 7 = 17.
  20. 20. Spinal accessory nerve XI • Inspect SCM for wasting or hypertrophy and palpate them to assess bulk. • Stand behind patient and inspect trapezius • Ask patient to shrunk shoulders and apply downward power to assess muscle power. • Assess SCM power by examining it against resistance
  21. 21. Hypoglossal nerve XII • The tongue is deviated to the affected side. • Usually lower motor neuron lesion • Lesion in contralateral side