Cranial nerve physical examination

Question 1

How do you assess CNI (olfactory)?

Answer 1

Asks about recent change in sense of smell

Tests if recent change - Alcohol swab to L&R

Question 2

How do assess CNII (optic nerve)?

Answer 2

5. Visual Acuity
   Uses Snellen/logMAR chart
   Tests one eye at a time, keeps glasses on
   Determines best level of reading and converts to score (L&R)
   If unable to read chart, uses number of fingers/hand moving/response to light
6. Visual Fields - screening
   Screening test - both eyes, upper and lower quadrants
   Unilateral and bilateral [inattention] stimulus
7. Visual fields confrontation
   Positions self at same level at patient, gets patient to cover eye and examiner covers the opposite, tells patient to look at nose
   Hand halfway between patient and examiner, comes in from each quadrant
   Tests R and L eyes
8. Fundoscopy (mention only)
9. Pupillary Responses (with III)
   Inspects pupils for size and symmetry, comments on ptosis
   Light reflexes - direct and consensual (L&R)
   Swinging torch (relative afferent pupillary deficit)
   Accommodation - from distance to about 30cm

Question 3

How do you assess CNV(trigeminal)?

Answer 3

11. Motor
    Clench teeth, palpate for masseters (L&R)
    Open mouth and hold it open, while examiner tries to close it
12. Sensation
    Facial sensation in all 3 division: ophthalmic, maxillary and mandibular (L&R)
    Use cotton wool “Does it feel the same?”
13. Reflexes
    Corneal reflex (mentions only)
    Jaw jerk

Question 4

How do you assess CNIII,IV,VI(oculomotor, trochlear, abducens)?

Answer 4

15. Extraocular movements
 Voluntary movements
 Follow "H" and asks if any double vision
 Correct instructions to the patient
 Correct interpretation

Question 5

How do you assess CNVII(facial)?

Answer 5

17. Facial nerve
     Observes for facial symmetry
     Frontalis: Wrinkle forehead, examiner to try to push down (L&R)
     Orbicularis Oculi: close eyes and examiner tries to open (L&R)
     Buccinator: puff out cheeks and hold (L&R)
     Orbicularis oris: show teeth
     Correct instructions to the patient
     Correct Interpretation

Question 6

How do you assess CNVIII(vestibulocochlear)?

Answer 6

19. Hearing
 Screening test - L&R (whisper)
 Correct instructions to the patient
 Correct interpretation
20. Rinne's
 Correct tuning fork (256Hz or 512Hz)
 Strikes tuning fork to make appropriate noise, places on mastoid, waits till bone conduction no longer clearly
audible and then checks air conduction (L&R)
 Correct instructions to the patient
 Correct interpretation
21. Weber's
 Correct tuning fork (256Hz or 512Hz)
 Strikes tuning fork to make appropriate noise, places on centre of forehead and checks which side (if any)
sounds the loudest
 Correct instructions to the patient
 Correct interpretation
22. (if applicable)
 Able to decide if L or R, Sensory or Conductive hearing loss
23. Nystagmus
 Gaze track horizontally out to 30 degrees R & L
 Gaze track vertically to 30 degrees R & L
 Test of skew
 Correct instructions to the patient
 Correct interpretation

Question 7

How do you assess CNIX and X (glossopharyngeal and vagus)?

Answer 7

25. Palatal Movements
 use torch, open mouth, say "ahh"
 Comments on symmetry and rise
 Correct instructions to the patient
 Correct interpretation
26. Gag reflex (mentions only)
27. Cough Assessment (mentions only)

Question 8

How do you assess CNXI(accessory)?

Answer 8

29. Accessory
     Sternocleidomastoids - turn head and examiner tries to push back (L&R)
     Trapezius - shrug shoulders and examiner tries to push them down (L&R)
     Correct instructions to the patient
     Correct interpretation

Question 9

How do you assess CNXII(hypoglossal)?

Answer 9

31. Hypoglossal
 Use torch to inspect tongue
 Asks patient to poke out tongue
 Correct instructions to the patient
 Correct interpretation