OSCE

Wednesday, November 29, 2017 2:44 PM

Cranial Nerve Testing

CNI - Smell/Olfaction (EXPLAIN)

- use non-irritating specific odors, don’t use noxious stimuli which can trigger CN V
1. Inspect nose for obstructive materials
2. Have patient close eyes, occlude one nostril and ask them to inhale scent and have them attempt to identify
3. You can use another scent in other nostril and withhold scents for false positives

CNII - Vision (PERFORM)

- The use of Snellen eye charts. If they wear glasses/contacts have them use it and document
1. Place eye chart at appropriate distance with adequate lighting
2. Ask patient to cover one eye and read from top row to the lowest that they can without errors (document)
3. If they can't read the biggest number, move HALF the distance up to the patient and ask them to Count Fingers
and mark (CF @ X)
4. If they can't count fingers, ask if they see your hand moving (HM @ X)
5. If they can't see hand, ask if they see light from penlight (LP @ X) or (NLP @ X) light perception/no light perception
6. Repeat with other eye

- Use of vision testing (Pseudoisochromatic Plates) (PERFORM)

1. Position plates 2.5 feet away with adequate lighting
2. Have them read all numbers and mark errors
3. Add errors up at the end of book to confirm normal or colorblind

- Confrontation Visual Field Testing (PERFORM)

1. Sit at arm's length and have patient cover left eye while you cover right eye
2. Have them look directly into your eye (testing peripheral)
3. Test top/bottom, bottom/up, temporal/nasal, and both outer diagonal corners
4. Then swap your hand and test nasal/temporal

- Mapping the blind spot (PERFORM)

1. Close left eye and hold both thumbs straight out in right eyes center field
2. Fixate on the left thumb and move right thumb temporally and see if top of thumb disappears (15 -20 degrees)
a. Papilledema increases size of blind spot

- Extraocular eye muscles (PERFORM)

1. Perform H-Test and remember that the actions the eye does is opposite for the sides when testing
2. Finger should be 1.5 feet away from patient's face, make sure to go all the way to the end of their vision
3. Perform H test and observe for nystagmus
4. When back at the middle (8) point, bring finger to nose and inspect for convergence and pupils constrict
a. Note even with MLF and PPRF, you should be able to observe this

Green arrows are testing

- Red markings are normal muscle eye movements
Pupillary Light Reflex (a:CNII / e:CNIII) (PERFROM)
Remember testing muscles and movement of muscles get swapped
1. Ask patient to fixate on something behind you at a far point
2. Inspect for ptosis, color, shape and size of pupil
3. Bring light from the temporal side to nasal and inspect for direct constriction as well as consensual constriction

Papilledema - blurred disk margins

- Fundoscopy (PERFORM)
1. Remove glasses (pt and ex), have minimal lighting
2. Ask patient to fixate on distant point over shoulder
3. Inspect with R-R-R, L-L-L rule (patients eye, side of patient, and your hand)
4. Being 15cm from patients eye and look for red reflex
5. Locate vessel and find pathway to optic disk
6. Inspect, both superior vessels, inferior vessels, optic disk (color) and macula densa (Fova Centralis)

Diabetic retinopathy (late) Age Related Macular Degeneration

Retinal detachment

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 Retinal detachment

CNV/CNVII
- Corneal Reflex Testing (EXPLAIN)
1. Use wisp of cotton, approach from side and touch cornea (this is the pain/noxious stimuli of CNV)
2. Observe facial blink muscles from CNVII

- Sensory testing for CN V (PERFORM)

1. Use cotton swab and stroke over V1, V2, V3 and ask patient to point to where you stroked (eyes closed)

- Masseter / Jaw Jerk Reflex a:CNV/ e:CNV (PERFROM)

1. Inspect symmetry of muscle density of the masseter
2. Palpate masseter, ask patient to clench teeth
3. Ask patient to place jaw in half open position
4. With thumb over tip of jaw, strike with reflex hammer and observe (strike downward)
a. Exaggerated reflex suggests UMN rostral to trigeminal motor nucleus

- CNVII Sensory (taste) (EXPLAIN)

- Taste of anterior 2/3 of tongue
1. Give bitter, sour, sweet, salty with tongue protruded and eyes closed, ask to identify
2. Rise mouth before each taste

- Facial Expressions (PERFROM)

1. Observe symmetry to face
2. Ask patient to wrinkle forehead or raise eyebrows - Frontalis
3. Ask patient to close eyes and resist opening with your thumbs - orbicularis oculi
4. Puff out cheeks, hold against resistance - buccinator
5. Ask patient to purse lips - orbicularis oris
6. Ask patient to make a grimace fact - Platysma

- Otoscopy (PERFORM)
1. Inspect around ears (lumps, lesions, deformities, burns)
2. Tug auricle up down and press tragus, ask patient to clench teeth (pain?) - otitis externa
3. Press firmly behind ear - otitis media
4. Place otoscope in correct position, use biggest cover
5. Insert and inspect for…
a. Discharge, foreign bodies, redness
b. Light reflex lower facial quadrant, color and contour of tympanic membrane
c. Malleus and perforations to membrane

CNVIII - Vestibulocochlear

- Auditory Testing (PERFORM)

- For Auditory testing, use 512 Hz tuning fork
- Weber
○ Place tuning fork in center of head and ask if they hear it on both sides and equally.
○ Make sure the two forks are in a coronal section
▪ Conductive hearing loss = louder side is damaged side
▪ Sensory neuronal loss = louder side is undamaged side
- Rinne
○ Explain process and place tuning fork on mastoid process, record time it takes until the patient can no longer
hear
○ Now move the tuning fork in front of ear (forks still in coronal placement) and record time until they no
longer hear it
▪ AC should be at LEAST twice the time as BC
▪ If BC>AC then this confirms conduction, if AC>BC but both low or AC>BC=0 then sensorineural

- OKN (Visual Pathway) (PERFORM)

- Using OKN tape, place 1.5 feet away from patient's face and ask to focus eyes straight on (black or white) stripes
- Observe for normal physiological nystagmus due to Optokinetic Reflex

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 - OKN (Visual Pathway) (PERFORM)
- Using OKN tape, place 1.5 feet away from patient's face and ask to focus eyes straight on (black or white) stripes
- Observe for normal physiological nystagmus due to Optokinetic Reflex

- Rotating Chair Experiment (EXPLAIN)

- Place person in chair and spin
- You will note that the first eye reflex will be the vestibular-ocular reflex because the initial movement will cause
fluid flow in the vestibular organ and cause an ipsilateral fast beating nystagmus

- Once in motion, the fluid in your vestibular organ will reach the same velocity and the rotation, you will now use
the ocular-kinetic reflex to keep the physiological ipsilateral fast beating nystagmus

- Once you stop the chair, you will have a contralateral fast beating nystagmus because the fluid in the vestibular
organ will still be in motion but stimulating the opposing organ

- Comatose Testing (EXPLAIN)

- Doll's maneuver (testing vestibular-ocular reflex)
○ As you rotate the head, the eyes will should still move to fixate on what was initially in center
▪ If eyes are always looking straight ahead in the direction of head, then suspect brainstem lesion
▪ Some pre-existing conditions or drugs (like barbiturates) will give false positive
- Caloric Testing
○ Lay person semi-supine (30 so that horizontal semicircular canal is in vertical position
○ Put cold water in ear, this will inhibit the ipsilateral vestibular organ so that the contralateral is stimulating
causing a slow movement of the eyes toward the cold water. Remember these people do not have the fast
beating nystagmus because that is conscious control.
○ Put warm water in ear, this will activate the ipsilateral vestibular organ causing the slow movement of the
eye away from the ipsilateral side

CNIX and X Glossopharyngeal and Vagus

- PERFORM
- With penlight, ask patient to open mouth and examine palate. Then ask patient to say "ah"
- Look for deviated uvula or non-raised palate
○ Deviated uvula is contralateral (LMN)

- EXPLAIN
- You could also have them drink a cup of water and observe for any dysphagia

- You can also perform gag reflex testing (perform only if suspected dysarthria (hoarseness) or dysphagia (difficulty
swallowing)
- To perform, use tongue depressor to touch one side of pharynx, then test other

CNXI Accessory Muscle

- PERFORM
- Walk behind patient and visualize shoulders (look for any asymmetry)
- Test Trapezius in front of patient
○ Ask to shrug shoulders
○ Then have them shrug shoulders against resistance

- Test SCM together

○ Place hand in forehead and ask them to lean forward against resistance of palm, both SCM will be
contracted, make a C-Clamp with one hand and palate, then palate other SCM with same hand

- Test SCM individually

○ Place hand on shoulder and other hand on ipsilateral side of cheek, ask to turn to that same side against
resistance. Observe for strength
▪ Remember you are testing the opposite SCM side

CNXII Hypoglossal
- PERFORM
- Ask patient to open mouth
- With pen light inspect tongue for atrophy, asymmetry, and/or fasciculations
- Ask patient to protrude tongue (look for any ipsilateral deviation)

SENSORY TESTING
should be performed for people with c/o of sensory issues
Test side to side, distal to proximal
Demonstrate testing on expected normal side first with eyes open
Ensure demonstration is clear and patient is understands

Nociception (PERFROM)
- Sharp and dull (pin prick/soft edge) explain that you want only those two options as responses
- Intersperse stimuli along different dermatomes (if doing C8 on left arm, then do C8 on right arm, then do another
dermatome)
- Alternate randomly from sharp and dull

Hot/cold (EXPLAIN)
- Fill test tubes with hot/cold water (explain what hot/cold feels like with eyes open)
- Place tube over skin and ask if it's hot or cold (eyes are closed)

Two-point Discrimination (PERFORM)

- Start at distal finger with pins almost together and ask if one or two?

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Hot/cold (EXPLAIN)
- Fill test tubes with hot/cold water (explain what hot/cold feels like with eyes open)
- Place tube over skin and ask if it's hot or cold (eyes are closed)

Two-point Discrimination (PERFORM)

- Start at distal finger with pins almost together and ask if one or two?
- Once they say "one" widen the gap until they say two, then move proximally
- Alternate between lateral and medial side of arm

Proprioception (PERFORM)
- Stabilize the joint by placing hands on sides of the proximal bone of joint and hands on sides distal to joint
- Move the distal part up or down and ask patient where it is (use sides of fingers!)
- Do 5 tests, if not normal, move to the next joint (Can do fingers and/or toes)
- Test other limb

Vibration (PERFORM)
- Test with 128-256Hz fork demonstrate with ulnar palm what vibration feels like
- Close eyes, perform on distal phalanx of index finger or great toe
- Ask if its vibrating or not (test with vibrations or no vibrations)

MOTOR TESTING
Being with simple observation, posture, chorea, asymmetry, resting tremors, etc.
Test muscle groups proximal to distal
- PERFORM
- Observe Bulk and grasp for bulk
○ Look for any atrophy
○ You could measure with tape (not performed)
- Tone
○ Grab hand and elbow and test ROM for tone
○ Grab tight and foot and test ROM of knee for tone
○ Observe for hypotonia, hypertonia or rigidity
- Strength
○ Perform resistance testing on arms and legs (these were not detailed)

Test Reflexes (PERFROM)

- C5/6 Biceps brachii and/or brachioradialis
○ Biceps, press firmly on tendon, arm relaxed on thigh, swing at finger
○ Brachioradialis, feel for tendon, 1cm lateral to radial pulse at styloid process, then move up 8 -10cm
▪ hammer perpendicular to muscle fibers
○ Contraction of biceps and/or flexion/supination of forearm

- C7/8 Triceps
○ Support arm with your arm and feel for triceps tendon, strike perpendicular

- L2/4 Quadriceps (knee-jerk)

○ Move sure patient is sitting high and legs not touching ground
○ Stand at side (don't get kicked)
○ Swing reflex hammer down

- S1/2 Triceps surae (ankle-jerk)

○ Patient should face chair and kneel on it (let foot overhang)
○ Dorsiflex the foot until you get resistance
○ Swing hammer, observe for plantar flexion (contraction of calf muscle)

Abdominal Reflexes (T8-T10 and T11-T12) (EXPLAIN)

- Patient should be supine, expose nipple line to public symphysis
- Stroke abdomen with hammer moving obliquely
- Start at costal margins for top and anterior superior iliac spine for bottom
- Look for ipsilateral abdominal contractions and umbilical deviation to stroked side

Cremaster Reflex (L1-L2) (EXPLAIN)

- Stroke anterior medial proximal thigh to scrotum, ascending testicle ipsilaterally

Anal Wink (S1) (EXPLAIN)

- Stroke perianal skin for contraction of external anal sphincter

Plantar Response (PERFORM)

- Patient sitting with feet dangling or laying supine
- Stroke sole of foot with hammer from heel to lateral ball of foot moving medially
- Great toe should plantar flex
○ UMN will be dorsiflex

NOTES
- With tests that involved closing eyes, demonstrate on the persons sternum
- Do everything bilaterally!

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- Do everything bilaterally!

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