Cranial Nerve Exam

8/7/2019 Cranial Nerve Exam

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CRANIAL NERVESOLFACTORY

Block one nostril, use good coffeeUnilateral loss= meningioma or increased ICPBilateral loss= trauma

OPTICLook at the pupils. Different sizes? = ANISOCORNEA

SCOPE THE FUNDUS: weirdness? Pale disk, hemorrhages etc?

TEST ACUITY: get their glasses off, use Snellen chartNormal = able to read line 6 at 6 metres(1st number = seen by pt)(2nd number = seen by normal person)

VISUAL FIELDS:Look into my eyes; see wiggling finger?(come INTO field, not out of it)

BLIND SPOT:come from the lateral, its normally @ temporal visual field

Scotoma?

PUPILLARY REFLEX:shine light into pupil:watch: what is the OTHER pupil doing?

Should also constrict

SWINGING LAMP SIGN:Move light to contra pupil:the ipsi pupil will then DILATE after the light hasmoved away from it.This is an AFFERENT PUPILLARY DEFECT(eye with reduced acuity will dilate abnormally)

ACCOMODATION:Near and far focussing

NORMAL ACCOMODATION BUT NO LIGHT REFLEX? = Syphilis pupil


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TRIGEMINAL

CORNEAL REFLEX: expect both eyes to blinkIf only contra eye blinks = ipsi 7th palsyIf touch is still felt, trigeminal nerve is intact

FACIAL SENSATION: forehead, cheek, chinTotal loss = preganglionic, eg. acoustic neuroma

Dissociated = brainstem issueMASSETERS: clench teeth

ABNORMAL MOVEMENTSJaw tremor? =. ParkinsonsRepetitive chewing? = Tardive DyskinesiaTetanus clench

JAW JERK REFLEXOpen mouthStrike lower chinNormally: NO REFLEX

EXAGGERATED = UMNL or pseudobulbar palsy

FACIALLOOK : Facial asymmetry?

Unilateral droop?Wrinkle smoothing?Loss of NASOLABIAL FOLD?

MUSCLE POWER:Wrinkle forehead; try to smooth outTest facial expressions:

- SURPRISE- GRIN- SNARL- POUT- PUFF- SQUINT

TASTE @ Ant 2/3rds

ACOUSTICLOOK @ EAR

Pull pinnaPain =. Otitis externa or TMJ disease

FEEL FOR NODESOTOSCOPE THE DRUMSTEST HEARING: 256 Hz fork:

Rinnes Test:Put struck fork @ mastoid:When you cant hear anymore:Put fork in front of ear.SHOULD BE ABLE TO HEAR IT AGAINIf not = conductive loss

Webers Test:Put struck fork on centre of glabellaShould hear it all @ centre of headNERVE-DEAF = better @ Normal earCONDUCTION-DEAF = better @ Clogged ear


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SENSORY AND MOTOR SYSTEMSGeneral template:

LOOK :- scars- wasting- fasciculations

- tremor- symmetry- abnormal movements

FEEL MUSCLE BULKTONEPOWERREFLEXESCOORDINATIONLower = GAIT

Upper= Fine Functions

PAIN with needleTemperature with ice cube

Vibration with tuning fork @ bony prominences

Proprioception with eyes closedLight Touch with cotton bud

UPPER LIMB MOTORShake hands;

Cant relax grip = myoclonusFasciculations? Wasting?

CLOSE EYES, HOLD OUT BOTHHANDS WITH PALMS UP:Drift UP = cerebellumDrift DOWN = UMNLSearching drift = pseudoathetosis,

= proprioception loss

TONEPOWERREFLEXES:Biceps, Triceps, brachioradialis

COORDINATIONClose eyes, touch own noseOpen eyes, touch my finger

DYSDIADOCHOKINESIS

LOWER LIMB MOTORGAIT:1. Walk normally2. Walk heel-to-toe = cerebellum3. Walk on toes = S1-S24. Walk on heels = L4, L55. Rombergs test

Fasciculations?Wasting? LOOK AT THE QUADS

TONEPOWERREFLEXES:Knee jerk, Achilles tendon,Babinsky (Normal = scrunch)

COORDINATIONtouch my finger with your toe

foot tappingHeel along shin


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CEREBELLUMINTRODUCE SELF, ASK PATIENT HOW THEY FEEL:Mr. Cerebello will reply EXPLOSIVELY + MONOSYLLABICALLY

Stand the patient up.GAIT:

walk back and forth,walk heel-to-toe

Cerebello will stagger affected side

CLOSE EYES + STAND WITH FEET TOGETHER(Rombergs test)Cerebello will sway + collapse

OPEN EYES, FOLD ARMSSwaying = trunkal ataxia

SIT DOWN, PUT ARMS OUT + HOLDCerebello will OSCILLATE

CLOSE EYES, PUT ARMS OUTCerebello will OVERSHOOT (rebound)

CLOSE EYES, TOUCH NOSECerebello will MISS HIS NOSE

OPEN EYES, TOUCH MY FINGERCerebello will have an INTENTION TREMOR

PRONATE + SUPINATE HAND, QUICKLYCerebello will have DYSDIADOCHOKINESIS

NYSTAGMUSCerebello will have

JERKY HORISONTAL NYSTAGMUS

SIT ON EDGE OF BED, SWING LEG LIKE PENDULUM

Cerebellos leg WILL NOT STOP SWINGING

LIE DOWN, RUN HEEL ALONG ANT. TIBIACerebello WILL NOT BE ABLE TO DO THIS PROPERLY

TOUCH MY FINGER WITH YOUR BIG TOECerebello will have an INTENTION TREMOR

STANDING

SITTING

SUPINE

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Cranial Nerve Exam