OSCE Neuro Examine Cranial Nerves 8-12

## Washes hands, appropriate dress and grooming. Introduces self, asks patient's name and age. Asks for consent

* Hello my name is [Medical Student] and I'm a first year medical student at [Medical School], can I please get your full name and age please?
* My Doe, today my attending physician has asked me to examine your cranial nerves, do I have your permission?

## Explains procedure to patient, positions and drapes

* For today's examination, I'll be testing your hearing, parts of your mouth, and your shoulder muscles, are you comfortable with this?
* I just want to remind you that anything we find will be confidential.
* Is there anything I can get you before we begin?
* The patient is sitting upright and is properly draped.

## INSPECT for: ear lesions or discharge, symmetrical soft palate, muscle asymmetry for the trapezius and sternocleidomastoid.

* I'm going to check the patient's ear for lesions or discharge.
	+ I don't see any signs of lesions or discharge.
* I'm going to stand behind the patient and check for symmetry of the trapezius muscles.
	+ Both trapezius muscles look symmetrical.
* I'm now going to look for atrophy (wasting) or fasciculations (twitching) of the trapezius muscles.
	+ I don't see any signs of atrophy or fasciculations.
* I'm now going to check for symmetry of the sternocleidomastoid muscle.
	+ Both sternocleidomastoid muscle look symmetrical.

## CN8: Perform WEBER and RINNE test and report findings. Describe what the findings of these tests would be for a conductive vs a sensory neural hearing loss.

* Weber Test:
	+ I'm going to perform the Weber Test by placing the base the tuning fork on top the head to test bone conduction.
	+ Mr. Doe, can you hear sound in both ears?
		- Sound heard in both ears is normal.
* Rinne Test:
	+ I'm going to perform the Rinne Test by placing the base of the tuning fork on the mastoid bone.
	+ Mr. Doe, I'm going to place the tuning fork near your ear, please say "now" when you no longer hear the sound.
	+ \*After the patient no longer hear the sound, place the prongs of the tuning fork near the ear\*
	+ Can you still hear the sound?
		- Yes means there's normal hearing.
		- Normally sound is heard longer through air than through bone.
			* (AC > BC) / Air Conduction > Bone Conduction
* If **Bone Conduction** is **greater** than **Air Conduction** and sound is heard in the **affected** ear, this can suggest **conductive** hearing loss seen in:
	+ Otitis Media
	+ Eardrum Perforation
	+ Ear Canal Obstruction
* If **Air Conduction** is **greater** than **Bone Conduction** and sound is **heard** in the **good** ear *but* **not** in the bad ear, this can suggest **sensorineural hearing loss** seen in:
	+ Constant exposure to loud noise
	+ Drugs
	+ Inner ear infection
	+ Aging

## CN 9: Ask patient to say "ahhh" and comment on finding.

* Please say "ahh" Mr. Doe.
* \*Use penlight\*
* I see symmetrical rise with the uvula at the midline which is normal.
	+ Asymmetrical rise can suggest unilateral Cranial X lesion.
	+ No rise can suggest bilateral Cranial Nerve X lesion.

## CN 10: Describe how to elicit a GAG REFLEX and neural pathway for this.

* I'll like to take this time to talk about the GAG Reflex.
* The GAG Reflex is elicited by stimulating the back of the throat lightly on each side with a Q-tip.
* Unilateral absence of the Gag Reflex can suggest a Cranial Nerve X or XI lesion.

## CN 11: Asses strength of SCM and and trapezius and comment on findings

* Mr. Doe, I'm going to stand in front of you and put my hands on your shoulder.
* Please shrug your shoulders.
* The patient was able to shrug his shoulders against resistance which is a normal sign.
	+ Trapezius weakness can suggest and disorder of the Peripheral Nervous System.
	+ Trapezius paralysis can suggest a Cranial Nerve 11 lesion.
* Mr. Doe, I'm now going to put my hands on your face, please turn your head against my hand.
	+ The patient was able to turn his head against my hands which is normal.
	+ Trouble turning his head can suggest Sternocleidomastoid paralysis caused by a Cranial Nerve XI lesion.

## CN 12: Ask patient to PROTRUDE TONGUE and comment on findings. Describe findings on central CN 12 lesion.

* Mr. Doe please stick out your tongue.
* I do not see any deviation in the tongue.
	+ Deviation away from the side of the lesion can suggest a Central Cranial Nerve XII lesion.
	+ Deviation toward the side of lesion can suggest a Peripheral Cranial Nerve XII lesion.
* That's the end of your exam, thank you for coming in.