Clinical Examination Guide

Cranial

Introduction

• Introduce yourself, confirm patient ID • Explain examination and gain consent, position patient sitting in a chair directly opposite you • Gel hands

Background

Cranial Component Structures Function I Olfactory Sensory Olfactory epithelium Smell II Optic Sensory Vision III Oculomotor Motor Superior, Inferior and medial rectus, Inferior oblique Levator palpabrae Parasympathetic Pupillary constrictor and ciliary Pupil constriction and muscles accommodation IV Trochlear Motor Superior Oblique Eye movement V Trigeminal Sensory Face, scalp, cornea, nasal and oral General sensation cavities, cranial Motor Muscles of mastication Open/close mouth Tympanic membrane tension Parasympathetic Salivary and lacrimal glands Salivation, lacrimation VI Abducens Motor Lateral rectus Eye movement VII Vestibulochochlear Sensory Vestibular apparatus Vestibular sensation IX Glossopharyngeal Sensory , posterior 2/3 tongue General sensation and Eustachian tube, middle ear General sensation Carotid body and sinus Chemo- and baro- reception

Document Owner: Clinical Skills/LK Last Updated: May 2019

Motor Stylopharyngeus Parasympathetic Salivation X Vagus Sensory Pharynx, , oesophagus, Salivation external ear Aortic bodies, aortic arch Chemo- and baro- reception Thoracic and abdominal viscera Cardiovascular, respiratory and GI control XI Accessory Motor Sternomastoid and Head and shoulder movement XII Hypoglossal Motor Intrinsic and extrinsic muscles of the Tongue movement tongue

General Inspection

• General inspection of patient: well/unwell, obvious asymmetry or paucity of movement in head, face and/or eyes? • Aids: glasses, hearing aids

I Olfactory

• “Do you have any difficulty, or have you noticed any changes in your of taste or smell?”

II Optic, III Oculomotor, IV Trochlear, VI Abducens

Screening Visual Inattention • “Do you have any problems with your vision?” • Position patient sitting 0.75m away with both eyes • “Do you normally wear glasses? If so, please use open them for the examination” • Outstretch your hands, with patient looking at your nose, ask them to indicate when they see your Inspection finger wiggle • Inspect eyes for , lid retraction, • Test left, right and both together for both upper exophthalmos, enophthalmos and lower fields

Visual Acuity: Fields • Ask patient to cover one eye and start reading • Ask patient to cover one eye (you mirror this) from the top of the Snellen Chart from 6m distance • With patient looking at your nose, outstretch your – average acuity is the ability to read line 6 at 6m arm and starting in upper quadrant field, move • Repeat with the other eye your hand diagonally to the centre • Document as “VA 6/x with/without • Ask patient to indicate when they first see your glasses/pinhole” (where x is lowest line the patient finger can read). • Test all four quadrants, comparing with your own • If they fail to read the top line, assess acuity with view. Repeat for the patient’s other eye counting fingers, hand movement or detection of • To test for central vision, ask “Can you see my light at 1m face, are any parts missing?” • Test blind spot as clinically relevant by using a red Colour Vision neurotip to map out the limits of the blindspot for each eye, asking patient when it appears and • Use Ishihara 24 plates if relevant disappears.

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Eye Movements: • “Focus and follow my finger, whilst keeping your • As patient looks in distance, inspect the pupils for head still” normal diameter and symmetry; the irises and • At 30-50cm distance from patient’s face, move conjunctiva your finger in exaggerated H shape to test all eye • Accommodation: Ask patient to track your finger movements as you bring it close to their face. Check for equal • “Do you have any , double vision or pupil constriction blurring?” • Direct and consensual pupillary : Ask patient • Look for: or restricted eye movement look to the distance, shine a pentorch in one eye, looking for a direct response (pupil constriction) in Fundoscopy that eye and consensual response in the other eye. Repeat both eyes • See other resources for guidance • RAPD: Move the pentorch from one eye to the other and check for any bilateral dilatation suggesting relative afferent pupillary defect

Control of eye movement

V Trigeminal

Inspection Facial Sensation • Look for wasting of temporalis muscles • Ask patient to close eyes • Using cotton wool ask patient to tell you when they Motor function feel it touch and whether it feels normal. First • Ask patient to clench and unclench teeth - look and demonstrate on their sternum feel for symmetry of masseter and temporalis • Touch (by dabbing with cotton wool) each sensory muscles division of the i.e. forehead, cheek • Ask patient to open mouth wide - look to see and jaw. whether jaw deviates (deviates towards a side of • Ask the patient to tell you if they can feel it, and if it lesion) feels the same both sides • Ask patient to open their mouth - attempt to close it with one hand Conjunctival Reflex, Jaw Jerk, Pain Sensation • Ask patient to move their jaw side to side • Not done at undergraduate level

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VII Facial

Inspection • Look at face at rest for asymmetry at nasolabial folds, forehead, wrinkles and angle of mouth

Motor function: • “Close your eyes tightly and stop me opening them” • “Raise your eyebrows and stop me pulling them down” • “Puff out your cheeks, don’t let me push them in” • “Please purse your ” • “Can you try and whistle”. Note any asymmetry and whether they naturally smile after doing this as absence of naturally smiling after whistling can indicate emotional paresis as in Parkinson’s • “Smile and show me all your teeth”

VIII Vesitubolcochlear

Hearing: Vestibular function: • “Have you noticed any difficulty with your • Unterberger/Turning test and Hallpike’s hearing? Or with your balance?” manoeuvre (not required in standard examination, • Gross hearing test: “Repeat the number I whisper see ENT examination guide) in your ear whilst I rustle my fingers in the other ear”. Repeat both ears • Rinne and Weber (not part of standard examination, see ENT examination guide)

IX Glossopharanygeal and X Vagus

Inspection: • Ask patient to open mouth and inspect uvula to see if central or deviated • “Say Aaah.” Look for symmetrical movement of the pharyngeal arches upwards and outwards. • “Do you have any difficulty swallowing?” • “Please cough.” Listen to quality of cough • Gag reflex is not tested at undergraduate level

XI Accessory

Inspection Power • Look for wasting, fasciculations, any abnormal • “Shrug your shoulders, don’t let me push them head movement down” • “Turn your head to the right, don’t let me push it back” • “And turn to the left…”

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XII Hypogossal

Inspection: • Look at tongue for any wasting or fasciculations at rest • “Stick out your tongue, move it from side to side”. Check for any deviation

Conclusion

• Thank patient, report/record findings • Consider , hearing test, fundoscopy

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