Cranial Nerves

______________

General
- LOC,
- brudzinksi sign (flexion of hips during passive flexion of neck =
meningism),
- kernig = flex each hip in turn, then attempt to straighten the keen with
hip flexed (limited in meningism)
- handedness
Orientation
-person, place, time "name, present location, date" -> MMSE
Position - legs over the side of the bed
Insp - craniotomy scars, neurofibromas, facial assymmetry, pupil equality, ptosis,
proptosis, skew deviation of eyes, cavernous haemangioma, shingles
1st olfactory
- be sure both nasal passages are patent by asking them to close one nostril
with a finger and breath through it at a time
- with one nostril occulded and eye closed
- use hospital isopropyl alcohol wipes, ask if problem with sense of smell
- repeat on other side
- if abn = examine nasal passage
- anosmia (URTI, smoking, basal skull #, Kallmann, meningioma, meningitis)
2nd optic -
acuity (snellen or hand held eye card)
."do you normally wear spectacles to read"
.pt should wear glasses if they nromally do so
.test each eye separately, covering the other
.hold at arms length, read the lowest line you can see clearly
.swap over, cover your other eye, hold the chart

fields
.examined by confrontation with a red hat pin
.examiner is on the same level as the patient and facing them
."cover your right eye with your hand" (examiner cover's their own left
eye with their left hand)
."focus on my nose"
.(using your right hand holding the hat pain) move the pin from
diagonals and horizontal OUT to IN direction
.if visual acuity is too poor - use your fingers with waggling
.try and determine blind spot
.try and determine colour desaturation

Bates video alternative = screening

face patient - head on same level as patient
place hands on either side of patients head (~30 cm each side)
start waggling your fingers and move them forward along an imaginary
fish bowl until the patient can see them
repeat at the diagonals and the horizontals

-concentric dimunition = tunnel vision (glaucoma, retinal

abn/chorioretinitis, retinitis pigmentosa, papilledema, ischaemia, migrain)
-central scotoma = macular dgen, MS demyelination of optic nerve,
methanol, glioma of optic nerve
-bitemporal hemianopia - optic chiasm, pituitary tumor,
craniopharyngioma, suprasellar meningioma
-homonymous hemianopia = optic tract or radiaion
-homononymous quadrantanopia = temporal or parietal lobe
 fundi / optic discs
.dim lights and ideally with pupil dilatation
."please stare into the distance"
.start ophthalmoscope on setting +20 shoudl allow cornea to be focus -
ulcers
.start at arms length away, with holding the scope in your right hand
to your right eye, and approach their right eye.
.increase setting to zero to see the fundi
.(right eye for patients right eye, left eye for the lef)

.optic cup = colour, margins, width

.optic disc N = yellow
.blurring of margins = papilledema

3rd oculomotor, 4th trochlear, 6th abducens = pupils and eye movement
-shape, releative size of pupils and any ptosis
-pocket torch, moving it from side to assess reaction to light
-direct and consensual responses
-afferent pupillary defect - move torch in arc from pupil to pupil
-accommodation - "look into distance (pupil dilation)....and now at this
hatpin (30 cm from nose, pupil constriction)"
-eye movement
.both eyes together following it in "H"
."do you see double at all" (diplopia)
.nystagmus ?
.convergence as you move a finger toward their nose
5th trigeminal:
-corneal sensatino and reflex
.do you wear contacts
.cotton wool to side of cornea as they are looking toward their nose
(sensory = CN5, motor = CN7) try bilateral
-facial sensation (pin prick and light touch - ophthalmic, maxillary,
mandibular)
.do you feel the pin prick on your chest
.close your eyes
.prick the 3 CN5 divisions: forhead, cheeks, jaw
.test symmetry
.if abn try temprerature
.light touch with cotoon - same locations
-motor - masseter, pterygoid, jaw jerk
.clench teeth while feeling masseter muscles (angle of mandible)
.try and open mouth (while you try and keep it shut) = pterygoids
.unilateral pterygoid lesion = deviation toward weaker affected side
.jaw jerk (incr in pseduobulbar palsy)
7th facial - musscles of facial expression + taste ant 2/3 tongue
- look up and wrinkle forehead - ? loss of wrinkling, try to push down
(preserved in UMNL bc of bilateral cortical)
- close your eyes and try to stop be from pulling them open
- smile showing your teeth (assymmetry ?)
- puff out cheeks
8th vestibulocochlear - hearing
- whisper a number "14" softly into each ear from 60 cm away + distract the
other ear with rubbing fingers together
- nerve vs conductive deafness
.rinne 256 Hz = mastoid = moved to external meatus (normal = air >>
bone conduction). COnduction deaf (bone > air)
.weber = forehead = normal (bilateral heard). Nerve deafness = louder
on side of normal ear. COnduction = better on side of unaffected ear.
-examine for external auditory canal and ear drum
9th glossopharyngeal + 10th vagus
-9th = sensory for nasopharynz, palate sensation, taste to posterior 3rd
tongue
.use a torch and a tongue depressor
.say ahhh - symmetrical movement of soft palate. Unilateral lesion =
uvula goes toward normal side.
.Touch palate sensation
.please say hello - hoarseness
.cough - bovine = bilateral recurrent laryngeal nerve lesion
.swallow - difficulty, regug
.gag reflect (elevation of palate)
-10th = sensory to - pharynx, larynx; motor to pharynx, larynx, palate
-
11th accessory - trapezius and sternomastoid mm
- shrung your shoulders agains resistance
- look toward wall pushing against my hand
-look for torticollis
12th hypoglossal = tongue
- wasting and fasisculation
- protrude the tongue
- unilaterla lesion = deviation toward weaker affected side

Sensory
_______
supine, eyes closed
sharp or dull
compare sides, distal and proximal: upper arms, dorsum hand, thigh, dorsum feet

anterior trunk: Lt vs Rt breast

If abn - test response to temperature

Light touch with cotton: breasts, stomach, upper arms, hands, thigh, feet
Compare sides

Vibratory 125Hz
_______________
distal interphalangeal joint of finger
if diminished move proximal to wrist/elbow
Toe -> ankle -> patella -> iliac crest

Position sense
______________
hold sides of big toe
move it up and down with their eyes open to show them
eyes closed
move toe
same for index finger

Stereagnosis
_____________
test identificaiton of key in hand and button in another

Graphisthesia
_____________
draw number in their palm

2 point discrimination
_____________________
finger pad
are you being touched with 1 or 2 sharp points
determine minimum distance between points at which they can tell (N = 5 mm)

Point discrimination
____________________
close your eyes
point to where I am poking you - trunka nd legs