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Cranial Nerve & Eye Exam

I: Olfactory II: Optic III-IV-VI: extraocculars V: Trigeminal VII: Facial VIII: Vestibulocochlear IX-X: Glossopharyngeal, Vagus XI: Accessory XII: Hypoglossal

CN I: Olfactory

  • Usually not tested.
  • Rash, deformity of nose.
  • Test each nostril with essence bottles of coffee, vanilla, peppermint.

CN II: Optic

  • With patient wearing glasses, test each eye separately on eye chart/ card using an eye cover.
  • Examine visual fields by confrontation by wiggling fingers 1 foot from pt’s ears, asking which they see move.
  • Keep examiner’s head level with patient’s head.
  • If poor visual acuity, map fields using fingers and a quadrant-covering card.
  • Look into fundi.

CN III, IV, VI: Occulomotor, Trochlear, Abducens

  • Shine light in from the side to gauge pupil’s light reaction.
  • Assess both direct and consensual responses.
  • Assess afferent pupillary defect by moving light in arc from pupil to pupil. unne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time.
  • “Follow finger with eyes without moving head”: test the 6 cardinal points in an H pattern.
  • Look for failure of movement, nystagmus [pause to check it during upward/ lateral gaze].
  • Convergence by moving finger towards bridge of pt’s nose.
  • Test accommodation by pt looking into distance, then a hat pin 30cm from nose.
  • If MG suspected: pt. gazes upward at Dr’s finger to show worsening ptosis.

CN V: Trigeminal

  • Corneal reflex: patient looks up and away.
  • Touch cotton wool to other side.
  • Look for blink in both eyes, ask if can sense it.
  • Repeat other side [tests V sensory, VII motor].
  • Facial sensation: sterile sharp item on forehead, cheek, jaw.
  • Repeat with dull object. Ask to report sharp or dull.
  • If abnormal, then temperature (heated/ water-cooled tuning fork), light touch (cotton).
  • Motor: pt opens mouth, clenches teeth (pterygoids).
  • Palpate temporal, masseter muscles as they clench.
  • Test jaw jerk (pseudobulbar palsy).

CN VII: Facial

  • Inspect facial droop or asymmetry.
  • Facial expression muscles: pt looks up and wrinkles forehead.
  • Examine wrinkling loss.
  • Feel muscle strength by pushing down on each side because of bilateral innervation.
  • Pt shuts eyes tightly: compare each side.
  • Pt grins: compare nasolabial grooves.
  • Also: frown, show teeth, puff out cheeks.
  • Corneal reflex already done.

VIII: Vestibulocochlear (Hearing, Vestibular rarely)

  • Dr’s hands arms length by each ear of pt.
  • Rub one hand’s fingers with noise on one side, other hand noiselessly.
  • Ask pt. which ear they hear you rubbing.
  • Repeat with louder intensity, watching for abnormality.
  • Weber’s test: Lateralization
  • 512/ 1024 Hz [256 if deaf] vibrating fork on top of patients head/ forehead.
  • “Where do you hear sound coming from?”
  • Normal reply is midline.
  • Rinne’s test: Air vs. Bone Conduction
  • 512/ 1024 Hz [256 if deaf] vibrating fork on mastoid behind ear. Ask when stop hearing it.
  • When stop hearing it, move to the patients ear so can hear it.
  • Normal: air conduction [ear] better than bone conduction [mastoid].
  • If indicated, look at external auditory canals, eardrums.

CN IX, X: Glossopharyngeal, Vagus

  • Voice: hoarse or nasal.
  • Pt. swallows, coughs (bovine cough: recurrent laryngeal).
  • Examine palate for uvular displacement. (unilateral lesion: uvula drawn to normal side).
  • Pt says “Ah”: symmetrical soft palate movement.
  • Gag reflex [sensory IX, motor X]:
  • Stimulate back of throat each side.
  • Normal to gag each time.

CN XI: Accessory

  • From behind, examine for trapezius atrophy, asymmetry.
  • Pt. shrugs shoulders (trapezius).
  • Pt. turns head against resistance: watch, palpate SCM on opposite side.

CN XII: Hypoglossal

  • Listen to articulation.
  • Inspect tongue in mouth for wasting, fasciculations.
  • Protrude tongue: unilateral deviates to affected side.

EYE EXAM

History

  • Presenting complaint:
  • Onset: gradual vs. sudden vs. asymptomatic.
  • Duration: brief vs. continuous.
  • Location: focal vs. diffuse, unilateral vs. bilateral.
  • Eye Hx: squint, amblyopia, glasses, glaucoma.
  • Family Hx: squint, lazy eye, glasses, glaucoma, cataract (young person).
  • Past medical Hx: especially vascular (diabetes, hypertension).
  • Medications: current meds, Hx of drugs affecting eye.
  • Is pt on or been on eye drops.
  • Social Hx: relevant post-op (to put eye drops in).

Inspection

In all, looking for asymmetry, deformities, discoloration, redness, discharge, lesions.

  • Diagnostic faces.
  • Orbit, rim: palpate for lumps.
  • Brow: lost sweating (Horner’s).
  • Eyelids: xanthelasma, ectropian, entropian.
  • Eyelids: pus on lids (blepharitis).
  • Ptosis.
  • Exophthalmos.
  • Iris: color, defects.
  • Cornea: transparent vs. opaque, corneal arcus, band keratopthy, Kayser-Fleischer rings, lesion, scars.
  • Ask the patient to look up and pull down both lower eyelids to inspect the conjunctiva and sclera.
  • Conjunctiva: clear/infected. If conjunctivitis, wash hands immediately: viral form contagious.
  • Sclera: jaundice, pallor, injection.
  • Spread each eye open with Dr’s thumb, index finger. Ask pt to look to each side and downward to expose entire bulbar surface.
  • Eyeball tenderness.

Visual acuity

If eye pain, injury, visual loss, check visual acuity before rest of the exam or inserting medications into eyes [so don’t get sued].

  • Let pt to use glasses, contacts if available.
  • Put pt 20 feet from Snellen eye chart, or hold Rosenbaum pocket card 14 inches away.
  • Pt. covers an eye at a time with a card, reading smaller letters till stop.
  • Record smallest line read, eg. 20/40.

Visual fields

  • Stand 2 feet in front of pt, who looks in Dr’s eyes at eye-level.
  • Dr’s hands to side half way between Dr and pt, wiggle fingers, ask which they see move.
  • Repeat 2-3 to test both temporal fields.
  • If suspect abnormality, test 4 quadrants of each eye while card covers other.

Ophthalmoscope (fundi)

  • Darken room, adjust scope so light is no brighter than necessary.
  • Adjust aperture to a plain white circle.
  • Set diopter dial to zero, unless have a preferred setting.
  • Dr. uses left hand and left eye to examine the patient’s left eye.
  • Dr’s free hand onto the pt’s shoulder or forehead for control.
  • Tell pt to stare at wall.
  • Look through scope, shine light into pt’s eye from 2 feet away at a 45? angle.
  • See the retina as a “red reflex.”. Reflex: clear vs. opaque (cataract). Follow red color to move within a few inches from pt’s eye.
  • Adjust diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk, use this as a point of reference.
  • Inspect optic disk:
  • Color of disc: pink vs. pale.
  • Margins clear.
  • State of cup.
  • Inspect vessels: all 4 quadrants, veins are darker than arteries:
  • Bleeding, exudate.
  • Pigmentation, occlusion.
  • Inspect macula, by moving the scope nasally:
  • Foveal light reflex
  • Bleeding, exudate.
  • Edema, drusen

Pupils

  • Shape, relative size.
  • Light reaction: dim lights if needed.
  • Pt looks in distance; shine light in from side to gauge pupil’s light reaction. Record size, irregularity. ? Assess both direct (same eye) and consensual (other eye) responses.
  • Assess afferent pupillary defect by moving light in arc from pupil to pupil, and if left eye light makes right eye dilate, not constrict (Marcus Gunne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time.
  • Accommodation: pt alternates between looking into distance, and a hat pin 30cm from nose.

Corneal reflections

  • Shine a light from directly in front of the pt.
  • Corneal reflections should be centered over pupils.
  • Assess asymmetry (extraoccular muscle pathology).

Eye movements

  • “Follow finger with eyes without moving head”: test the 6 cardinal points in an H pattern. Assess:
  • Failure of movement.
  • Nystagmus [pause to check it during upward, lateral gaze]).
  • Convergence by moving finger towards bridge of pt’s nose.
  • Gaze palsies (supranuclear lesions).
  • Fatiguability (myasthenia).

Corneal reflex

  • Corneal reflex: patient looks up and away.
  • Touch cotton wool to other side.
  • Look for blink in both eyes, ask if can sense it.