OSCE Neuro Examine Cranial Nerves 1-2

## 1. Wash hands, appropriate dress and grooming. Introduces self and asks for consent.

* Hello my name is Yang Vang and I'm a first year medical student at AUA, can I please get your full name and age please?
* Mr. Doe, today my attending physician has asked me to examine your Cranial Nerves, do I have your permission?

## 2. Explains procedure to patient, positions and drapes.

* For today's examination we'll be checking your sense of **smell** and **vision**, are you comfortable with that?
* I just want to remind you that anything we discover will be **confidential**.
* Are you **comfortable**? Is there anything you need before we begin?

## 3a. Inspect the nasal cavities looking for blockage, discharge, etc. Inspect the eyes looking for anisocoria, conjunctivitis, subconjunctival hemorrhage.

* I'm going to inspect the nasal cavities with my **penlight**.
	+ I don't see any signs of **blockage** or **discharge**.
* I'm now going to inspect your **eyes**.
	+ I don't see any signs of Anisocoria in the eyes which is unequal pupil size.
	+ I do not see any signs of **narrow angle glaucoma**.
	+ I do not see any signs of **conjunctivitis**.
	+ I do not see any signs of **subconjunctival hemorrhag**e which are bright red spots in the conjunctival.
	+ I do not see any signs of **strabismus** which is misalignment of the eyes.

## 3b. CN1: Examine and comment on findings.

* Mr. Doe, can you please close one of your nostril and both your eyes.
* Can you tell me what you smell please?
* Now please close your other nostril; please tell me what you smell.
* Thank you Mr. Doe, you can now open your eyes.
* The patient was able to smell the scent which means Cranial Nerve I is intact.
* Loss of smell can indicate and:
	+ Sinus conditions
	+ Head trauma
	+ Smoking
	+ Aging
	+ Cocaine
	+ PD (Parkinson's Disease)

## 4. CN 2: Check Visual Acuity on Snellen chart and comment on finding.

* Mr. Doe, I'm going to check your vision now.
* Do you use reading glasses or contacts?
	+ If yes: Please put them on.
* **Far Vision**
	+ \*Stand 20 feet away with a Snellen eye chart\*
	+ Please cover one eye and read the smallest line.
		- Record the visual acuity findings.
	+ The patient's visual acuity is 20/30 which means that at 20 feet, the patient can read print that a person with normal vision can read at 30 feet.
	+ 20/20 is normal far vision.
	+ 20/ >20 is myopia.
* **Near Vision**
	+ \*Hold a piece of paper containing print 14" from the patient and ask them to read it.\*
	+ The patient was able to read the print, which means the patient does not have **presbyopia** or impaired near vision.

## 6. Check visual fields by confrontation and comment on finding.

* Okay Mr. Doe, I'm going to check for you visual fields now, please look at my eyes.
* I'm going to be moving my fingers towards you, please let me know when you see them.
* \*Repeat for upper and lower quadrants\*
* \*Findings\*
* The patient was able to see both sets of fingers at the same time which means his visual fields is normal.
* Some types of visual field defects are:
	+ **Horizontal** **defect** caused by **glaucoma**.
	+ **Unilateral blindness** caused by **optic neuritis**
	+ **Bitemporal blindness** caused by **pituitary tumor**.
	+ **Homonymous hemianopia** or **quadrantanopia** caused by **stroke**.

## 7. Tests direct and consensual pupillary reflexes and comment on finding. Describe findings in Horner's Syndrome, Argyll Robertson Pupils & Afferent Pupillary Defect (Marcus Gunn Pupil)

* Mr. Doe, I'm now going to check your pupillary reflex, please look straight ahead of you into the distance.
* \*Shine light into the pupil\*
* I was able to see constriction in the left eye.
* I was able to see constriction and consensual reaction of the pupils which is a normal pupillary reflex.
* If the pupil constricts to light but does not dilate in absence of light, this can suggest Horner's Syndrome.
	+ Other symptoms of **Horner's Syndrome** include:
		- Ptosis
		- Miosis
		- Anhydrosis
* Argyll Robertson Pupils
	+ Neurosyphilis
* Marcus Gunn Pupil
	+ Lesion of the Optic Nerve.

## 8. Check for accommodation and comment on findings.

* Mr. Doe, please follow my fingers with your eyes.
* I was able to see **pupillary** **constriction** when going from **distant** to **near**, this is a **normal** accommodation reflex.
* **Normal** accommodation with **abnormal** light reflex can suggest **Argyll** **Robertson** which is associated with **syphilis**.
* **Delayed** or **absent** pupillary reflex with **delayed** accommodation is associated with **tonic** **Adie's** **pupil**.
* **Fixed** dilated pupil with **no** light reflex and **no** accommodation is associated with **Cranial** **Nerve** **III** **paralysis**.

 **Argyll Robertson** | Yes
 **Adie's Pupil** | Delayed
 **CN 3 Paralysis** | No

* That's all for your exam today, thank you for coming in.