Cranial Nerve Top Tips

Station 3 - Neurology Exam – Cranial nerve

o Candidate will enter the station

o Candidate will wash their hands/use hand gel
o At the same time, candidate reads instructions on a sheet of A4 pinned to the
wall.
o Patient is lying on a couch with head of the couch elevated at approx 45° with one
pillow.
o Candidate approaches patient
o Checks their identity
o Introduces themselves
o Asks permission to examine patient.

Candidate carries out inspection from the end of the bed

o Looks around the bed for signs of reading material, hearing aid, glasses, etc.

Face inspection
o Candidate asks the patient if they have noticed any changes in their sense of smell
▪ “Have you noticed any recent change in your sense of smell?”
Visual acuity inspection
o Candidate asks the patient to read a resized Snellen chart. If the patient normally
uses distance glasses, ensure these are worn for the assessment. Candidate asks
patient to read, closing one eye at a time
▪ “Could I ask you to read this please? Can you cover one eye with
your hand please”
o If unable, test each eye by holding up 3 or 4 fingers and ask if the patient can tell
how many fingers they are holding up
▪ Can you please tell me how many fingers I am holding up?”
o If still unable, candidate asks patient if they can see the candidate’s hand moving
▪ “Can you please tell me if you can see my hand moving?”
o If still unable, candidate asks if patient is able to see a light from a pen torch when
shone into each eye
▪ “When I shine my torch into your eye, please let me know if you can
see any light.”
Visual field examination
o Candidate tests visual fields – initially testing for visual inattention by asking
patient to look at the candidate’s nose while holding both arms outstretched and
moving the fingers of both hands together, asking the patients which fingers are
moving
▪ “Please look at my nose. Please point to which fingers you see
moving”
o Candidate repeats at approx. 2/10 o’clock and 4/8 o’clock
▪ Please cover one eye with your fingers. Please tell me where you
can see my fingers moving
o Candidate also puts their hand over their opposite eye. Candidate tests each
quadrant for each eye (2, 4, 8 and 10 o’clock) and repeats with the other eye.
Cranial Nerve Top Tips

Visual field examination (red hat pin)

o Candidate tests visual fields with red hat pin. Candidate covers relative eye to the
one patient has covered
o Candidate asks: “Please look directly at my eye. Please tell me if you can see the
pin here”, etc
o Candidate draws small, central square shape with pin (checking the central visual
fields)
▪ “Please tell me when you see the pin come into your view”
o Candidate extends arm to each corner, and brings pin into the centre in small
segments
o Repeat with other eye.

Eye examination
▪“Please can I ask you to look at my finger and keep your head as still
as possible”
o Candidate moves finger in a ‘H’ shape to test all range of movement and
observing for restriction of eye movement, nystagmus or ptosis
▪ “Please tell me if you see double at any time”
o Candidate holds arms out horizontally, with one hand extended (palm) and one
hand balled (fist). Candidate asks patient to shift eyes between palm and fist in
turn
▪ “Please look at my palm or fist when I tell you”
o Candidate switches position to hold arms vertically and repeats.

Accommodation Reflex
o Candidate tests the accommodation reflex by observing the pupils while placing a
finger approximately 15cm in front of the eyes then asking the patient to focus on
a distant object then the finger
▪ Please look at my finger, now the poster on the wall, and again at
my finger.”

Facial sensation (Cotton wool)

▪ “May I please test the sensation on your face?”
▪ “Please say yes when you feel the cotton wool”
o Candidate uses the cotton wool
▪ “Can you feel it here?” by using the cotton wool on the forehead,
cheek and jaw
o Candidate tests both sides of the face and asks
▪ “Does it feel the same on both sides?”
o Candidate then tests sensation using a pin.

Facial sensation (eye)

o If necessary, candidate uses the edge of a sterile piece of cotton wool and asks
the patient to look away while gently touching the edge of the cornea
▪ “I now want to test the sensation in the eye”
o Candidate repeats on other side.
Cranial Nerve Top Tips

Motor examination (Face)

o Candidate will ask
▪ “Now please clench your teeth”

Face examination (Shoulders)

▪ “Please shrug your shoulders”
▪ “Please keep them shrugged up”
o Gently pushes against each shoulder

o Candidate feels the bulk of the masseter and temporalis bilaterally

▪ “Now please open your mouth loosely, and don’t let me close your
mouth”
o Candidate pushes against the chin gently
▪ “Please let your mouth hang open slightly”
o Candidate places one finger just under the bottom lip and taps gently downwards
with a tendon hammer.

Facial movement examination

o Candidate will ask the patient to follow the following instructions:
▪ “Please raise your eyebrows as high as they go”
▪ “Please close your eyes as tightly as you can”
▪ “Please show me your teeth”
▪ “Now purse your lips as tight as you can”
o Candidate repeats the above, attempting to provide resistance to each area,
asking candidate “I’m going to try and open your eyes/mouth – don’t let me”.

Ear examination
“May I now test your hearing?”
▪
“Have you had any change in hearing recently?”
▪
o Candidate blocks the opposite ear and rustles fingers next to the ear and asks,
“Can you hear it ticking?”
▪ “Can you hear the noise?”
o Candidate repeats process on the other side.

Face Examination (mouth)

▪ “Now please open your mouth wide”
o Candidate uses a pen torch to Assess soft palate and uvula and then says
▪ “Please say ‘aaah’”
▪ “Can I ask you to cough?”

Face examination (tongue)

▪ “Please open your mouth again”
o Candidate inspects the mouth + tongue, looking for any wasting of the tongue at
rest on the floor of the mouth
“Please stick out your tongue”
“Please move your tongue from side to side as fast as you
can”
“Now please push your tongue into your cheek”
“Don’t let me push”
Cranial Nerve Top Tips

o Pushes against the tongue

o Candidate repeats for other cheek.
“Please turn your head to the right”
▪
“Now please push your head against my hand”
▪
o Candidate repeats on other side
o Candidate palpates each sternomastoid.

End of examination.
o Candidate thanks the patient and asks them to get dressed
▪ “Thank you for letting me examine you.”

Top tips to remember for your examination.

o When introducing yourself always consider facies, then hands for signs of
weakness or muscle wasting. Consider if the patient is using all four limbs.
o Power. Compare each muscle group with the contralateral side. Ask the patient to
fix a position and then resist you attempting to overcome that position for flexors
and extensors at the hip, knee and ankle in the lower limb or shoulder, elbow,
wrist and fingers in the upper limb.
o Reflexes. Compare one reflex with contralateral side. When examining plantars
use a small blunt stick and draw slowly up the lateral aspect of each foot then
across the ball of the foot. Gently hyperextending the knee with your free hand
accentuates the response.
o Coordination. In the upper limb the finger-nose test should be with the patient’s
arm fully outstretched, and keep your finger moving slowly from side to side. Test
for dysdiadochokinesia by rapidly tapping on the back of one hand with the fingers
of the contralateral hand and then tapping when rapidly pronating and supinating
the contralateral hand. Rocking of the elbow indicates abnormal coordination.
o Sensation. Test for sensory inattention with light touch on the dorsum of both
hands in unison with the patient's eyes closed. Use pin in a dermatomal
distribution. Initially, use the tuning fork to test temperature - “Does it feel cold”
– before testing vibration. Test joint position sense initially with the patient’s eyes
open to ensure they understand what is being requested.
o Pupillary reflex. Test for a light reflex from an ophthalmoscope. Absent direct and
preserved consensual reflex suggests blindness in that eye. Check the corneal
reflex is symmetrical, then evaluate the red reflex in each eye before examining
the fundus.
o Visual fields. Initially, evaluate visual inattention by asking the patient to look at
your nose with both eyes open and point to which finger is moving, while moving
fingers of both hands at the extreme of peripheral vision, repeated in upper and
lower quadrants. Then repeat with the patient keeping one eye closed (while you
keep the opposite eye closed) with one finger moving in all four quadrants. Repeat
for the other eye.
Cranial Nerve Top Tips