Flashcards in OSCE Prep Deck (40):
What is cranial nerve 1, what does it do, and how do you test it?
assess patency of nostrils; occlude one nostril at a time and ask patient to sniff
with eyes closed, occlude one nostril and present an aromatic substance - odor should be normally identified through each nostril
What is cranial nerve 2, what does it do, and how do you test it?
Test visual acuity and test visual fields by confrontation
Test visual acuity by snellen eye chart or near vision test
Confrontation normal ranges are 50 degrees up, 90 degrees temporally, 70 degrees down, and 60 degrees nasal
what is cranial nerve 3 and what does it do?
Extra ocular muscle movement, opening of eyelids
pupil constriction and lens shape
what is cranial nerve 4 and what does it do?
Down and inward movement of eye
what is cranial nerve 5, what does it do, and how do you test it?
Muscles of mastication
Sensation of face and scalp, cornea, mucous membranes of mouth and nose
assess muscles of mastication by palpating the temporal and masseter muscles as the patient clenches their teeth - muscles should feel equally strong on both sides; next try to separate the jaw by pushing down on the chin - normally you cannot
test sensory function by touching patients cheeks, chin and forehead with a cotton wisp, while their eyes are closed, asking them to say "now" whenever the sensation is felt - this tests all 3 divisions of the nerve (ophthalmic, maxillary, and mandibular)
what is cranial nerve 6 and what does it do?
Lateral movement of eye
what is cranial nerve 7, what does it do, and how do you test it?
Facial muscles, close eye, labial speech, close mouth
Taste (sweet, salty, sour, bitter) on anterior two thirds of the tongue
Saliva and tear secretion
Note mobility and facial symmetry as patient responds to your request to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth, and puff cheeks - then press patient's puffed cheeks in and note whether the air escapes equally from both sides
Only test sensory function when you suspect facial nerve injury - when indicated, test sense of taste by applying to the tongue a cotton applicator soaked in a solution of sugar, salt, or lemon juice (sour). Ask patient to identify the taste
What is cranial nerve 8, what does it do, and how do you test it?
Hearing and equilibrium
test hearing acuity by determining the patient's ability to hear normal conversation or by the whispered voice test
What is cranial nerve 9, what does it do and how do you test it?
Pharynx (phonation and swallowing)
Taste on posterior one third of tongue, pharynx (gag reflex)
Parotid gland, carotid reflex
Depress the tongue with the tongue blade, and note pharyngeal movement as the patient says "ahhh" or yawns; the uvula and soft palate should rise midline, and the tonsillar pillars should move medially
Touch the posterior pharyngeal wall with a tongue blade and note the gag reflex - also note that the voice sounds smooth and not strained.
Sensory function - technically too difficult to test
what is cranial nerve 10, what does it do, and how do you test it?
Pharynx and larynx (talking and swallowing)
General sensation from carotid body, carotid sinus, pharynx, viscera
Tested with cranial nerve 9, the glossopharyngeal nerve
What is cranial nerve 11, what does it do, and how do you test it?
Movement of trapezius and sternomastoid muscles
Examine the sternomastoid and trapezius muscles for equal size. Check equal strength by asking the patient to rotate the head forcibly against resistance applied to the side of the chin. Then ask the patient to shrug the shoulders against resistance. These movements should feel equally strong on both sides
What is cranial nerve 12, what does it do and how do you test it?
Movement of tongue
Inspect the tongue. No wasting or tremors should be present. Note the forward thrust in midline as the patient sticks out the tongue. Also ask the patient to say "light, tight, dynamite" and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct
How do you test cranial nerves 3, 4, and 6? (oculomotor, trochlear and abducens)
Check pupils for size, regularity, equality, direct and consensual light reactions and accommodation
Assess extraocular movements with the 6 cardinal positions of gaze
Endpoint nystagmus - a few beats of horizontal nystagmus at extreme lateral gaze - is normal
What areas do you need to assess in inspection and palpation of the motor system?
Muscles - for size, strength, tone, and any involuntary movements
Cerebellar function - balance tests (gait and the romberg test), coordination and skilled movements (rapid alternating movements, finger-to-finger test, finger-to-nose test, heel-to-shin test)
How do you assess the sensory system?
First, ensure the validity of sensory system testing by making sure that the patient is alert, cooperative, and comfortable, and has an adequate attention span;
Spinothalamic tract (pain, temperature, light touch)
Posterior column tract (vibration, position, tactile discrimination)
Inspect and palpate the motor system - muscles (size)
size - inspect all muscle groups for size, comparing right side with left; muscle group should be within normal limits for ages and should be symmetrical bilaterally; if extremities look asymmetrical, measure each in centimeters and record -- a difference in 1 cm or less is not significant
Inspect and palpate the motor system - muscles (strength)
test the power of homologous muscles simultaneously; test muscle groups of the extremities, neck and trunk
Inspect and palpate the motor system - muscles ( tone)
tone is the normal degree of tension (contraction) in voluntary relaxed muscles; it is demonstrated as mild resistance to passive stretch; to test muscle tone, move the extremities through a passive range of motion; first, persuade patient to relax completely, then move each extremity smoothly through a full range of motion, support the arm at the elbow and the leg at the knee; normally you will note a mild, even resistance to movement
Inspect and palpate the motor system - muscles (involuntary movements)
normally none are present, but if they are you note their location, frequency, rate and amplitude, and whether they can be controlled at will
Assess cerebellar function
Coordination and skilled movements
How do you test balance? - gait
Gait - have patient walk 3-6m, turn and return to starting point; normally a person will move with a sense of freedom; gait should be smooth, rhythmic, and effortless; opposing arm swing is coordinated, turns are smooth, step length is approx 30 cm from heel to heel; tandem walking - ask patient to walk in a heel-to-toe manner, decreasing base of support; normally a person can walk straight and stay balanced.
Can also test balance by having patient walk on toes and then on heels for a few steps
How do you test balance? - Romberg test
ask patient to stand up with feet together and arms at sides; once he or she is stable, ask patient to close eyes and hold the position; wait approximately 20 seconds; normally a person can maintain posture and balance even when visual orientation is blocked, but slight swaying may occur; stand close to the patient in case he or she falls
Ask the patient to perform shallow knee bend of hop, first on one leg, then the other; this demonstrates normal position sense, muscle strength, and cerebellar function
Rapid Alternating Movements
ask patient to pat knees with both hands, lift up and turn over the hands, and pat the knees with the backs of the hands; then ask the patient to do this faster - normally this is done with equal turning and a quick rhythmic pace
Alternatively, ask the patient to touch the thumb to each finger on the same hand, starting with the index finger, then reverse direction. Normally this can be done quickly and accurately
With the patients eyes open, ask that he or she use the index finger to touch your finger and then his or her own nose. After a few times, move your finger to a different spot. The patient's movement should be smooth and accurate.
Ask the patient to close the eyes and to stretch out the arms. Ask the patient to touch the tip of his or her own nose with each index finger, alternating hands and increasing speed. Normally, this movement is accurate and smooth.
Test lower extremity coordination by asking the patient to assume a supine position, to place the heel on the opposite knee, and run it down the shin from the knee to the ankle. Normally, a person moves the heel in a straight line down the shin.
Spinothalamic tract - pain
tested by the patients ability to perceive a pinprick; break a tongue blade lengthwise, forming a sharp point at the fractured end and a dull spot at the rounded end; lightly apply the sharp point or dull end to the patient's body in a random, unpredictable order; ask the patient to say "sharp" or dull" depending on which sensation is felt; let at least 2 seconds elapse after stimulus to avoid summation. - if abnormal do a temperature test
Spinothalamic tract - light touch
apply a wisp of cotton to the skin; stretch cotton ball to lengthen it, and brush over the skin in a random order of sites at irregular intervals; this prevents patients from responding just from repetition; include forearms, arms, hands, chest, thighs, and legs; compare points symmetrically
Posterior column tract - vibration
test patient's ability to perceive vibrations of a tuning fork over bony prominences; use a low-pitch tuning fork, because its vibration has a slower decay; strike fork on the heel of your hand and hold the base on a bony surface of patients fingers or great toe; ask patient to indicate when vibration starts and stops; if patient feels the normal vibrations or buzzing on these distal areas, you may assume that the proximal areas are normal too; if no vibrations are felt, move proximally and test ulnar processes, ankles, patellae and iliac crests; compare right and left sides
PCT - Position (kinaesthesia)
test patients ability to perceive passive movements of the extremities; move a finger or a big toe up and down, and ask the patient to tell you which way it was moved; this test is done with the patient's eyes closed; normally, a person can detect movement of a few millimeters
PCT - Tactile discrimination (fine touch) - stereognosis
ability to recognize objects by feeling their forms, sizes and weights, with the eyes closed; place familiar objects (paper clip, key, coin, etc) in patients hand and ask them to identify it
PCT - Tactile disc. - graphaesthesia
ability to "read" a number by having it traced on the skin; ask the patient to close their eyes and use a blunt instrument to trace a single-digit number or letter in patient's palm; ask patient to tell you what character it is; this is a good measure of sensory loss if patient cannot make the hand movements needed for stereognosis, as occurs in arthritis
PCT - Tactile disc. - Two-point discrimination
ability to distinguish the separation of two simultaneous pinpoints on the skin; apply the two points of an open ended paper clip lightly to the skin in ever-closing distances; note the distance at which the patient no longer perceives two separate points; the level of perception varies considerably with the region tested; most sensitive in fingertips (2 to 8 mm) and least sensitive on the upper arms, thighs and back (40-75 mm)
PCT - Tactile disc. - Extinction
simultaneously touch both sides of the body at the same point; ask patient how many sensations are felt, and where they are; normally both sensations are felt
PCT - Tactile disc. - Point location
touch the skin, and withdraw the stimulus promptly; tell the patient "put your finger where I touched you"; you can perform this test simultaneously with light touch sensation
Test reflexes - five point scale for grading
4+ - very brisk, hyperactive with clonus; indicative of disease
3+ - brisker than average, may indicate disease
2+ - average, normal
1+ - diminished, low normal
0 - no response
C5 to C6 - support patient's forearms on yours; this position relaxes, as well as partially flexes the patient's arm place your thumb on the biceps tendon, and strike a blow on your thumb; you can feel as well as see the normal response, which is CONTRACTION OF THE BICEPS MUSCLE AND FLEXION OF THE FOREARM
C7 to C8 - tell patient to just let arm go limp as you suspend it by holding the upper arm; strike the triceps tendon directly just above the elbow; the normal response is EXTENSION OF THE FOREARM
C5 to C6 - hold patients thumbs to suspend the forearms in relaxation; strike the forearm directly, approximately 2 to 3 cm above the radial styloid process; the normal response is FLEXION AND SUPINATION OF THE FOREARM