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