Central Nervous System: Checklist PMPF Checklist PMPF

Chapter 5
Central nervous system

Checklist
Checklist
HELP:
H: Hello (introduction and gains consent)
Explains that needs to examine the nerves of the face
E: Exposure of head and eyes sits opposite the patient at
eye level
L: Lighting
P: Positions correctly (sits opposite patient at eye level), asks
if patient is in any pain
Washes hands
Inspection:
Facial asymmetry (stroke, parotid gland tumour)
Ptosis (complete cranial nerve III palsy, or partial
Horners syndrome)
Convergent or divergent squint (congenital or muscle/
nerve pathology)
Medical aids glasses, eye patch, hearing aids, pen and
paper for communication
Hearing aids (deafness peripheral or central cause)
Fasciculations (LMN)
Dyskinesia
Wasting (LMN, UMN, disuse atrophy)
Abnormal movements (tremor, chorea, myoclonus)
Speech defects (see Chapter 8 on speech)
Scars (back of ear acoustic neuroma, craniotomy; in
front of ear parotid gland tumour, and may have
associated ipsilateral facial nerve palsy)
Tracheostomy, nasogastric or PEG tubes (lower cranial
nerve dysfunction leading to breathing difficulties and
unsafe swallow)
P MP F
Cranial nerve II: optic nerve (sensory):

Any change in vision?
AFRO-C:
Acuity: With glasses (if worn), gets to the patient to
identify how many fingers are held up, and then tests
with a Snellen chart
Fields:
Confrontation (can the patient see the students
face? central vision)
Asks them to cover their right eye with their right
hand. Student covers their own left eye with the left
hand, and asks patient to keep looking into their
eye. Using free hand, student tests fields, and then
swaps hands and repeats on other side
During this part of the exam, maps the blind spot
(the area where the patients view of the finger
temporarily disappears)
Tests each eye separately: brings in fingers from
outside the field of vision. Does this match the
students field (peripheral vision)?
Pupillary Reflexes:
Comments on whether the pupils are the same size
Direct and consensual
Accommodation (pupils constrict on convergence)
Considers testing for relative afferent pupillary defect
(RAPD) damage to optic nerve on one side results
in a delay in constriction when swinging a light
between the eyes. Pupil appears to dilate when the
light is swung to the eye with the damaged optic
nerve
Red pins for colour desaturation
Fundi: See Chapter 6 on Ophthalmoscopy
Colour vision: Ishihara plates
Uses a pinhole to correct refractive error
Cranial nerve I: olfactory nerve (sensory):

Sense of smell can be tested with smelling salts
Any change/loss of smell?
Most likely cause of abnormal sense of smell is
conductive/mechanical (e.g. due to obstruction)
OSCEs for Medical Finals, First Edition. Hamed Khan, Iqbal Khan, Akhil Gupta, Nazmul Hussain, and Sathiji Nageshwaran.
2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
P MP F
Checklist
Cranial nerves III, IV and VI: oculomotor, trochlear, abducens
(all motor):
Tests nerves individually:
IV: superior oblique
Damage means eye is unable to look down when
abducted
VI: lateral rectus
Damage means eye is unable to abduct
III: Other movements: Examine smooth pursuit and
nystagmus with a hat pin moved in a H pattern
Damage causes dilated pupil, ptosis and restricted
eye movements
Look for exophthalmos
Double vision
Whether it is going across/up/down and in which
direction
Nystagmus
Cranial nerve V: trigeminal nerve (motor and sensory):
Tests sensation in three areas supplied by branches V1, V2
and V3 (light touch and pin-prick)
States intent to elicit a corneal reflex (wisp of cotton on
the sclera of the eye both eyes should blink)
Opens the patients mouth against resistance and moves
it from side to side (pterygoids)
Feels the temporalis and masseter muscles while the
patient clenches their teeth
Jaw jerk
Cranial nerve VII: facial nerve (motor and sensory):
Asymmetry look for a Bells palsy
Is the forehead spared?
Asks the patient to raise their eyebrows and shut their
eyes tight against resistance
Asks them to show their teeth
Asks them to puff out their cheeks
Taste in anterior two-thirds of the tongue
P MP F
Checklist
Cranial nerve VIII: vestibulocochlear (sensory):
Simple test of hearing whispers a number into each of
patients ears while rubbing the fingers next to the other
ear (to prevent the whisper being heard in that ear)
Rinne and Weber tests (256Hz tuning fork) see Hints
and tips for the exam below
States intent to perform caloric testing
Cranial nerves IX and X: glossopharyngeal and vagus (both
motor and sensory):
Assesses cough (bovine cough if Xth nerve lesion)
Listens and identifies hoarseness of voice
Asks patient to say Ah (uses a torch to see if the palate
rises uniformly bilaterally and the uvula is central)
Taste: posterior third of tongue
Offers to test gag reflex (using a tongue depressor,
carefully touches the back of the throat. Patient should
gag. Positive reflex shows intact afferent cranial nerve IX
and efferent cranial nerve X)
Cranial nerve XI: accessory (motor):
Asymmetry of muscles
Asks patient to shrug shoulders against resistance
trapezius
Asks patient to turn head to left and right against
resistance sternocleidomastoid
Cranial nerve XII: hypoglossal (motor):
Visualises tongue at rest (fasciculation)
Asks patient to protrude tongue (deviation)
Asks patient to moves tongue to left and right
Thanks patient
Offers to help patient get dressed
Washes hands
Presents findings
Offers appropriate differential diagnosis
Suggests appropriate further investigations and management
OVERALL IMPRESSION:
P MP F

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Chapter 5

Central nervous system

Cranial nerve II: optic nerve (sensory):

Cranial nerve I: olfactory nerve (sensory):

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