Hi, Good Morning, my name is Kayla Boyea and I'm a Fifth year medical student.

I've
been asked to examine your cranial nerves. This would just involve me examining your
eyes, your facial movements and your hearing, would that be okay?
Okay thank you.
And can I get your name please?
And how old are you?
Thank you
Are you in any pain?

On general inspection, i seea.Young female/male sitting comfortably in no obvious

cardiopulmonary distress, she appears to be of adequate nutritional status with no
obvious wasting.
On closer inspection of the face,I do not appreciate any facial asymmetry. I do not
appreciate any gross defects in the patients pupillary size, I also do not appreciate any
scarring.

Olfactory- I

I'm just going to start by asking you a question, have you noticed any change in your
sense of smell at all?

(Anosmia- early sign of Parkinson's )

I'm going to place an object by your nose, I want you to close your eyes and cover your
left nostril. I would like you to tell me when you smell it and tell me what it smells like.

Okay here we go:

Tell me when you smell it...and tell me what you smell.

Very good. And now close the other nostril, and tell me when you smell it and what you
smell.
Can you smell it equally on both sides?

Optic 11

Now I'm going to examine your vision would that be okay?

Can you stand for me please?

Do you wear glasses or contact lenses?

Count six steps away from the patient, walk there and turn around and face patient.

What I would like you to do is to look at this chart in my hand. Could you cover your
left eye, with the palm of your left hand and using your right eye could you read the
smallest line of letters possible. Fantastic. And could you do the same with the other
eye.

Very good.
_______ is displaying a visual acuity of 20/20.

And then do a best corrected visual acuity - using a pin hole test- it means there is a
refractive error

Visual fields

I'm now going to test your visual fields. Are you able to see my face in it's entirety? Are
there any parts that seem blurry? Okay.
Can you cover your left eye with your left Palm, and I'm going to cover the opposite
eye.
Now look straight at my nose and tell me when you see my finger moving (tell me as
soon as you see it come into view)
Move from all corners and come into the center.
And now the same with the other eye. Keep looking at my nose and tell me when u
see my finger moving. (As soon as you see it come into view).Very good.

Testting for visual fields with color

Testing central vision

Then put a red hat pin in the center, and move it in a small square, ask the patient if it
disappears at any time. Have the patient do this closing one eye at a time.
Cause- central scotoma.

Looking at my nose, can you point at the finger you see moving. (Do this 3 times, with one
finger, then the other, then both)
Thank you

There were no deficits in the patients visual field.

I'm now going to assess your pupils response to light.

Can you focus on the wall straight behind me.

Direct and consensual light reflexes

Can you stare at a focus point on the wall behind me, continue to stare at it while I do
the examination.

Shine light in each eye of the patient

The direct light reflex is normal bilaterally

The focus light in one eye, and swing light in and out of the other eye.
Do this for both eyes.
The consensual light reflex is also normal bilaterally
(Make sure the second light is under the eye to view consensual response)
THE MAIN REASON YOU DO A CONSENSUAL RESPONSE TO SEE IF THERE IS
AN EFFERENT PROBLEM)

And now I'm going to swing the light between your eyes

Detects Afferent pupillary defects

THIS IS THE MOST ACCURATE TEST FOR DETERMINING AN AFFERENT PROBLEM.
If you do the right eye, then left eye and then right eye, and the right eye dilates - there
is an AFFERENT problem in the right eye

Very good.
There is no obvious afferent pupillary defects

Ideally, now I would like to assess color vision using ishihara plates (color vision is the
first thing to go for optic nerve problems)

III, IV, VI- Occulomotor, trochlear, abducens

(If you look at the patient and there is aniscoria, you already know that there is a cranial
nerve III problem)

I'm not going to assess the movement of your eyes

On inspection..
There is no deviation of the eyes. There is also no Ptosis or proptosis noted.
Or any anisocoria.

Differences in the size of the pupil is caused by the parasympathetics of the third cranial
nerve.

Are you experiencing any double vision at all?

Okay.
Well please let me know if you experience any double vision during this Examintion.
Can you focus on my finger, and keeping your head still can you follow my finger.

During this exam say..

I'm observing for any nystagmus.
And make sure to ask the patient again if they see one finger or two

Accomodation

Now I'm going to ask you to focus your vision to the wall behind me again, and when I
say, can you look at my finger.
Now.

The accomodation reflex was normal and there were no Palsies of his 3rd, 4th or 6th
cranial nerve

Trigeminal nerve- V

On closer inspection of the face I do not appreciate any scars. There are no vesicular
lesions of the Trigeminal nerve.

I'm now going to test the sensation on your face, I'm going to start by using a piece of
cotton wool. What I want you to do is close your eyes, and let me know when you feel
the cotton wool and if it is the same on both sides.

This is what the cotton wool feels like

Place it on patients chest.
Can you feel it?
Okay now going to place it on your face
Say 'yes' when you feel it.
Place it in the six quadrants of the face

Now this is sharp,

This is what it feels like.
Every time I place it on your face say 'yes' when you feel it.
Okay great
Place it in the six quadrants of the face

There is normal sensation in the face

Just tighten the muscles by your eyes for me please, good.

And now tighten the muscles by your jaw.

Open your mouth slightly, don't let me close it.
And now can you close your mouth, don't let me open it.

That was cranial nerve 5 the motor component, that was normal throughout.

Open your mouth a bit.

Do jaw jerk

There was no abnormality in the jaw jerk reflex

Okay I'm going to place some cotton quickly in your eye, just to see how you brink in
response to it. Can you look up and towards the left for me please?

Place the cotton quickly.

Okay thank you
Repeat on the opposite site,

The corneal reflex tests both cranial nerve 5 and 7 concomitantly

Facial nerve - VII

For cranial nerve 7, there is no facial asymmetry noted.

Can you raise both your eyebrows for me?
Can you close both eyes for me tightly? Don't let me open them.Very good.
Can you smile?

Have you noticed any changes in your taste? Okay, thank you.

Can you push out your cheeks? Okay good

Don't let me push them in

There were no deficits in cranial nerve 7

Vestibulocochlear- VIII

Okay now I'm going to test your 8th cranial nerve.

I want you to close your eyes.
I'm going to place the tuning fork in the middle of your forehead, I want you to let me
know on which side you hear the sound better. (Whether you can hear it better in
either ear)

Okay great, there is no lateralization of the sound to either ear.

Now do rinnes test

Okay, now I'm going to place the tuning fork behind your ear. When I place it behind
your ear, first I want you to tell me if you can hear it. Then let me know when you stop
hearing it.

When the patient stops hearing it, then place it infront of patients ear and ask if they can hear
it now.

Repeat the same thing on the other side.

Air conduction is better than bone conduction in both ears.

Cranial nerves IX and X

Now open your mouth for me. Say 'Ah' very good. There is no deviation of the uvula

Test gag reflex

Accessory nerve- XI

On inspection there is no obvious wasting of the sternocleidomastoid.

Stand at the back of the patient
There is also no obvious wasting of the trapezi

Stand back at the front of the patient

Push up your shoulders for me.Very good.

Turn your head to this side for me.Very good.

And now turn your head to this side.Very good.
One hand placed on the cheek and the other on the opposite neck.

There are no abnormalities in cranial nerve 11

Cranial nerve 12- Hypoglossal nerve

Open up your mouth- say 'ah' let the tongue stay in resting position.

Stick out your tongue and move it from side to side. Great

Press your tongue against my finger, very good

And now the other side, very good.
Okay thank you sir, I'm done the Examintion.

Notes on cranial nerves:

Cranial nerve III

How to differentiate between:

First order
Second order
And third order Horners

Optic II
Main reason for an acute (posterior) Ischaemic optic neuropathy - men who take viagra,
cialis.
The time line of the problems, can give you a good idea for what the diagnosis is.

Anterior Ischaemic optic neuropathy/ posterior Ischaemic optic neuropathy

Etiology
Who does it present in
How does it present
What does the eye look like
Treatment

Papilloedema - optic disc edema/ swollen optic disc

* Do cup to disc ratio
Venous pulsations (if you see them, it means the patient does not have raised pressures in the
brain)

When you can't see the optic cup, you know it's less than 0.1
Small cup, increases risk of Ischaemic optic neuropathy

*Central retinal venous occlusion

reasons for the differences in the dot, flame , blot, and boat hemorrhages
Optic edema, possibly due to Papilloedema
Neuromyelitis optica

One of the most common causes of optic neuropathy: optic neuritis.

Optic disc edema won't have the torturous vessels, hemorrhages, exudates, that Papilloedema
would cause,

If you want to determine if the difference in pupil sizes is due to dilation or constriction,
you will additionally stress the pupil, by putting it in bright light or putting it in dim light.
Write down the pupillary gauge in both dim/dark and bright light.

oculomotor nerve palsy

Most common cause is a PCA aneurysm (posterior communicating artery) - pupil is
dilated and unreactive to light
Looking for the differences in anisocoria when stressed in dark/ bright light.
If the pupil size gets greater when the light is on..the problem is..
If you have a lesion from outside, the first guy you are affecting is the
parasympathetics, if you have a lesion from inside, you will just have damage to the
oculomotor nerve, not the parasympathetics. Pupil sparing third nerve lesion. Most
commonly cause by diabetic microinfarction due to occlusion of the vasa nervorum.
Partial third nerve palsy occurs if there is NO downward, and abduction of the eye
(exotropia).
Complete third nerve palsy, occurs if there is downward rotation and abduction of
the eye.
And if the pupil is not affected, there is a oculomotor nerve palsy, but it is a pupil
sparing third nerve palsy. Main causes - diabetes, hypertension.
Adies tonic pupil, comes into the differential diagnosis for Horners (Homes- Adie
pupil)
One form of light near association - Argyll Robertson pupil - occurs with brainstem
tumors in the dorsal brain (in general)
What is the accommodation pathway

Horners Syndrome
Partial Ptosis, due to the muellers muscle
You also get upside down Ptosis
In old age you get
Evaporates dehiscence, one way to tell if it's an actual problem, you can look at the
lower lid, if it is raised, there is a problem, because you have an upside down Ptosis.
Conjunctival injection happens in third order neuron Horners syndrome (eg. Carotid
dissection)

Some things of Horners syndrome

1. Eyelid Ptosis
2. Miosis
3. Anhidrosis
4. Conjunctival injection
5. Upside down Ptosis (causes apparent enopthalmos)
Stress the eyes to determine which pupil is affected.
Whenever the difference is greater...that is the problem.

How to differentiate between first, second and third order Horners

Pain in the eye- is more likely to be a third order Horners and an intracranial Horners
How to distinguish between 2nd and third order Horners:

*Remember if the pupils are equal, there is no EFFERENT defects

Visual fields

Get a medi pin

The fibers of the nasal retina are the ones that cross at the chiasm.
The temporal retinal fibers, remain ipsilateral, they do not cross over.

Superior fibers- parietal lobe

Inferior fibers - temporal lobe
" pie in the sky"

Cranial nerves III, IV and VI

5 causes of Ptosis:
Oculomotor palsy (levator palpebrae)
Horners syndrome (Muellers tarsal muscles)
Myasthenia gravis
Levator palpebrae dehiscence
Myopathy

Ways to measure Ptosis?

Quick movements are called - saccards - this is one of the first things to go when a
patient has inter nuclear opthalmoplegia.
Explanation of the figure H 2:45:00
What are you testing in each area Of the H test
In the abducting eye - you are testing the superior rectus
In the adducting eye - you are testing the inferior oblique

In the abducting eye (right eye) - you are testing the inferior rectus
In the adducting eye (left eye) - you are testing the superior oblique

If a person presents with double vision, what are the four questions you want to ask:
What happens when you cover one eye, does it go away ( if it doesn't, it is monocular
diplopia - this is opthalmologic- nothing to do with neurology- but do a pin hole test
before leave your clinic - because it may be a refractive problem )
Binocular diplopia, is more likely a neurological problem. (Listen to the voice note
right above this)
Question number 2- are the images side by side or one on above the other.
Causes of each - vertical or horizontal diplopia. One of the causes of INO is
horizontal.
Question number 3- Is it when your looking far or close? Far- lateral recti comes
into play, close - medial recti comes into play.
Question number 4- Is it worse at any time of the day? Does it get worse later in the
day?

Causes of diplopia
Myasthenia gravis
Giraves disease
III and IV cranial palsies
*****You do the cover-uncover test if the 'figure H testing' does not
show the tropia

For phorias- you have to do the cross-cover test

What are the different type of tropias?

In primary gaze you see it turned in- esotropia

In primary gaze you see it turned out - exotropia
If in the H test, it can't move in - exotropia
If in the H test, it can't move out - esotropia
If it's not getting up - hypotropia

Cover- uncover test:

If it moves outward - it is a esotropia ( you will see it when you cover the good eye,
causing the bad eye to fixate)

Detecting phorias

How to detect phorias

Incompetency- the weakness is greater with changes in position

Causes of abduction deficits

6th cranial nerve
Myasthenia gravis
INO
Graves' disease

What are the contents of the cavernous sinus?

Sympathetically run on top of the cavernous sinus

Vertical diplopia - 4th nerve palsy (most likely)

Trochlear nerve palsy - 3 step test