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.