Cranial Nerves: History + Exam Flashcards
What associated symptoms should be asked about in the SOCRATES review of a headache?
n&v altered consciousness rash pyrexia neck stiffness photophobia visual loss, blurred vision aura, seizures tender scalp malaise rhinorrhoea, lacrimation
What conditions might be in the differential diagnosis if symptoms are relapsing and recurring?
migraine
epilepsy
MS
What exacerbating/relieving should be asked about in the SOCRATES review of a headache?
exacerbating: noise, stress, bending, standing up, coughing, sneezing, blowing nose, eating, combing hair, bright/flashing lights, certain foods/drugs, dehydration
relieving: analgesia, dark environment, lying down, rest/sleep
What qs are important to ask in the history of an episode of altered consciousness?
describe in own words
onset - gradual/sudden? time of day?
what were they doing at the time? - pain, infections, hot crowded room, emotional stress, prolonged standing?
how they felt before the episode?
associated symptoms
recovery time? amnesia, aggression, crying or weakness afterwards? feeling sad/crying after episode?
previous episodes? were they like this one?
was it witnessed? what did they say, can we contact them?
What associated symptoms should be asked about in the history of an episode of altered consciousness?
dizziness, nausea, vertigo, aura, tachycardia, sweating, weakness, paraestoesia, slurred speech, headache, tongue biting/incontinence, stiffening/jerking of limbs, awareness/responsiveness during episode, eyes open or closed, groans or crying?
What is the most important factor to ask about any neurological symptom?
course
sudden in onset? how long to reach peak of symptoms? getting better or worse? static/progressive/relapsing + remitting?
What conditions should be specifically asked about in the PMH?
head/spinal trauma metabolic/endocrine disorders e.g. diabetes cancer, mets? epilepsy HTN AF heart diseases previous episodes?
What medications should be specifically asked about in the drug history?
anticonvulsants drugs that interact with anticonvulsants/lower seizure threshold anticoagulants/anti-platelets analgesics antihypertensives antidepressants insulin recreational drugs over the counter drugs
Whats factors are important to ask about in the social history?
alcohol consumption
smoking
recreational drugs
occupation
social activities/hobbies/daily living/driving
home circumstances/independence/family support/housing
Why is alcohol important to ask about?
can cause: seizures neuropathy ataxia Wernick-Korsakoffe syndrome (lack of thiamine)
What conditions should be specifically asked about in the family history?
diabetes cerebral haemorrhage cerebrovascular disease/stroke ischaemic heart disease migraine epilepsy
What 4 things need to be tested in a neurological exam?
- walking
- cranial nerves
- motor system
- sensory system
What does a Parkinson’s gait look like?
stooped posture, rigidity small shuffling steps wrists, elbows, hips and knees flexed no arm swing resting tremor
What does a hemiplegic gait look like?
weakness on one side > weak arm hands, drags 1 leg behind
What does a scissoring gait look like?
knees can flex and knock together
restricted stiff movement
What can cause a scissoring gait?
any condition causing spasticity
e.g. cerebral palsy
What does a steppage gait look like?
foot drops and toes drag so hips and knees flex excessively (high stepping)
foot stamps
What can cause a steppage gait?
common perineal nerve palsy
= weakness of dorsiflexion > high step to avoid falling
How is gait examined?
- normal heel to toe walk - look for posture, balance, stride length, arm swing
- tandem walk test - look for same things
- Romberg test - stand feet together with eyes closed, dr stands close, +ve = fall
What does a +ve Romberg test indicate?
proprioception problem
What is the first step in a cranial nerve examination?
general inspection of patient’s head and neck
look for: scars, neurofibromas, facial asymmetry, ptosis, proptosis, skew deviation of the eyes, inequality of the pupils
How is CN I: olfactory nerve examined?
ask if they have had any alteration in their sense of smell/taste > only test further if they report problems
olfactory testing bottles/easily recognised scents e.g. soap, coffee
test each nostril separately, occluding the other one with your finger
How is CN II: optic nerve examined?
- visual acuity
- snellen chart if available
- if not: cover one eye, ask them to state how many fingers you’re holding up/different font sizes from a newspaper
- wear glasses if they usually do
- if no glasses: pinhole test > won’t correct acuity in people with an optic nerve issue - visual fields
- sit 1m opposite pt with eyes at same level
- cover one of own eyes, pt covers eye opposite
- ask pt to stare into your other eye
- bring object/finger from point outside visual field diagonally into visual field
- ask them to signal when they first see it
- repeat in all 4 quadrants for each eye - visual inattention/visual extinction
- hold hands up in periphery of pts vision
- move tip of index finger up and down on one side at a time, then on both sides together
- ask pt to report which side is moving
- visual inattention/extinc = can detect if one is moving individually, ignores one side when both move at same time - direct and consensual light reflexes
- pt looks straight ahead
- bring light in from side so pt doesn’t focus on it
- shine light into eye and look for constriction of that pupil (direct light reflex) and the contralateral one (consensual light reflex) = both constrict
- check relative afferent pupillary defect
- swing flashlight between eyes > should remain constricted
- if one dilates = RAPD (problem in ipsilateral optic nerve)
- accommodation
- pt focuses on a distant point, then your finger, held - 30cm in front of their nose
- normal = constriction of both pupils - ophthalmoscopy, testing colour vision, assessing size of blind spot
On fundoscopy, what might a lost red reflex indicate?
cataracts
