OSCE Neuro Examine Cranial Nerves 8-12

Washes hands, appropriate dress and grooming. Introduces self, asks patient's name and age. 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?
 * My Doe, today my attending physician has asked me to examine your cranial nerves, do I have your permission?

Explains procedure to patient, positions and drapes

 * For today's examination, I'll be testing your hearing, parts of your mouth, and your shoulder muscles, are you comfortable with this?
 * I just want to remind you that anything we find will be confidential.
 * Is there anything I can get you before we begin?
 * The patient is sitting upright and is properly draped.

INSPECT for: ear lesions or discharge, symmetrical soft palate, muscle asymmetry for the trapezius and sternocleidomastoid.

 * I'm going to check the patient's ear for lesions or discharge.
 * I don't see any signs of lesions or discharge.
 * I'm going to stand behind the patient and check for symmetry of the trapezius muscles.
 * Both trapezius muscles look symmetrical.
 * I'm now going to look for atrophy (wasting) or fasciculations (twitching) of the trapezius muscles.
 * I don't see any signs of atrophy or fasciculations.
 * I'm now going to check for symmetry of the sternocleidomastoid muscle.
 * Both sternocleidomastoid muscle look symmetrical.

CN8: Perform WEBER and RINNE test and report findings. Describe what the findings of these tests would be for a conductive vs a sensory neural hearing loss.

 * Weber Test:Webber.jpg
 * I'm going to perform the Weber Test by placing the base the tuning fork on top the head to test bone conduction.
 * Mr. Doe, can you hear sound in both ears?
 * Sound heard in both ears is normal.
 * Rinne Test:1-0.png
 * I'm going to perform the Rinne Test by placing the base of the tuning fork on the mastoid bone.
 * Mr. Doe, I'm going to place the tuning fork near your ear, please say "now" when you no longer hear the sound.
 * *After the patient no longer hear the sound, place the prongs of the tuning fork near the ear*
 * Can you still hear the sound?
 * Yes means there's normal hearing.
 * Normally sound is heard longer through air than through bone.
 * (AC > BC) / Air Conduction > Bone Conduction
 * If Bone Conduction is greater than Air Conduction and sound is heard in the affected ear, this can suggest conductive hearing loss seen in:
 * Otitis Media
 * Eardrum Perforation
 * Ear Canal Obstruction
 * 4.png Air Conduction is greater than Bone Conduction and sound is heard in the good ear but not in the bad ear, this can suggest sensorineural hearing loss seen in:
 * Constant exposure to loud noise
 * Drugs
 * Inner ear infection
 * Aging

CN 9: Ask patient to say "ahhh" and comment on finding.

 * Please say "ahh" Mr. Doe.
 * *Use penlight*
 * I see symmetrical rise with the uvula at the midline which is normal.
 * Asymmetrical rise can suggest unilateral Cranial X lesion.
 * No rise can suggest bilateral Cranial Nerve X lesion.

CN 10: Describe how to elicit a GAG REFLEX and neural pathway for this.

 * I'll like to take this time to talk about the GAG Reflex.
 * The GAG Reflex is elicited by stimulating the back of the throat lightly on each side with a Q-tip.
 * Unilateral absence of the Gag Reflex can suggest a Cranial Nerve X or XI lesion.

CN 11: Asses strength of SCM and and trapezius and comment on findings

 * Mr. Doe, I'm going to stand in front of you and put my hands on your shoulder.
 * Please shrug your shoulders.
 * The patient was able to shrug his shoulders against resistance which is a normal sign.
 * Trapezius weakness can suggest and disorder of the Peripheral Nervous System.
 * Trapezius paralysis can suggest a Cranial Nerve 11 lesion.
 * Mr. Doe, I'm now going to put my hands on your face, please turn your head against my hand.
 * The patient was able to turn his head against my hands which is normal.
 * Trouble turning his head can suggest Sternocleidomastoid paralysis caused by a Cranial Nerve XI lesion.

CN 12: Ask patient to PROTRUDE TONGUE and comment on findings. Describe findings on central CN 12 lesion.

 * Mr. Doe please stick out your tongue.
 * I do not see any deviation in the tongue.
 * Deviation away from the side of the lesion can suggest a Central Cranial Nerve XII lesion.
 * Deviation toward the side of lesion can suggest a Peripheral Cranial Nerve XII lesion.
 * That's the end of your exam, thank you for coming in.