OSCE Neuro Examine Cranial Nerves 5 and 7

## Washes hands, appropriate dress and grooming. Introduces self and 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?
* Mr. Doe, today my attending physician has asked me to do examination of your Cranial Nerves, do I have your permission?

## Explains procedure to patient, positions and drapes

* Today examination involves me touching various parts of your face, are you comfortable with that?
* I just want to remind you that anything we find will be confidential.
* Is there anything you need before we begin?

## Test light touch in the three branches of the trigeminal nerve and comments on findings. Describe how to test for the corneal reflex

* I'm going to be touching you in difference places with this cotton, please close your eyes and say "yes" whenever you feel the touch.
* **Ophthalmic Nerve Tes**t:
	+ \*Touch the cotton to the patient's forehead; repeat on the opposite side.\*
* **Maxillary Nerve Test**:
	+ \*Touch the cotton to the patient's upper cheek; repeat on the other side.\*
* **Mandibular Nerve Test**:
	+ \*Touch the cotton to the patient's chin; repeat on the other side.\*
* The patient was able to feel the cotton in all areas.
* If the patient had isolated facial sensory loss, this could suggest **trigeminal neuralgia**.
* If the patient had **ipsilateral** *face* and **contralateral** *body* sensory loss, this could suggest a **stroke** at the *brainstem*.
* I would like to take this time to talk about the corneal reflex.
* This test is performed by approaching the patient from the side and touching the **cornea** (pupil+iris) of their eye with *cotton*.
	+ **Blinking** or tearing is the **normal** corneal reflex and suggest that Cranial Nerve 5 and 7 is intact.
	+ **No** **blinking** suggest *damage* to Cranial Nerve 5 or 7.

## Test strength of the muscles of mastication and comment on findings

* Mr. Doe, I'm now going to test your chewing muscles.
	+ \*Palpate both mastication muscle\*
		- Please clench your teeth for me.
	+ \*Palpate masseter muscles\*
		- Please clench your teeth again.
* Both the temporal and masseter muscles strength felt normal.
	+ If I were to feel **unilateral** weakness this, could suggest a **pontine lesion**.
	+ If I were to feel **bilateral** weakness, this could suggest **cerebral hemisphere disease**.

## Test jaw jerk and comment on findings

* Mr. Doe, can you please move your jaw from side to side please?
* The patient was able to move their jaw from side to side.
* Difficulty moving from side to side could suggest **pterygoid muscle weakness**.

## Inspects the face for evidence of CN 7 paralysis and explains the different findings for a central versus a peripheral lesion

* I do not see any **lip drooling** which can suggest a **central lesion** which is associated with paralysis of only the lower face.
* Lip drooling along with trouble closing the **eye**, **flat** **nasolabial** **fold**, and **no** **forehead** **wrinkling** can suggest a **peripheral lesion**.

## Test strength of muscles innervated by the facial nerve including eye closure, cheek puffing, smile, and wrinkling of forehead and comment on findings

* Mr Doe, I'm now going to test the muscles of your face.
	+ Please raise both eyebrows.
	+ Please frown.
	+ Please close both eyes as tight as you can while I try to open them.
	+ Please show me your teeth.
	+ Please smile.
	+ Please puff out both cheeks.
* The patient was able to perform all the task.
* This suggest the patient does not have *upper* or *lower* face *paralysis* associated with **trauma**, **Bell's Palsy** or **stroke**.
* That's the end of the exam, thank you come coming in today.