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Cranial Nerve Summative OSCE 2005
Lock Haven University Physician Assistant Program
Summative OSCE
Physical Diagnosis Skills Station
Student’s Name:
Date:
Time:
Evaluators’Name:
Grading Criteria
1) The item must be performed correctly, completely, and accurately.
2) The item must be performed with regard to patient’s comfort, safety or
feelings.
3) Student, when requested by faculty, must be able to explain the
technique or the reason (DiffDx) for the exam.
4)You must tell the examiner everything you are inspecting for or you
will not receive credit.
5)You must initiate all exams and continue unless instructor tells you to
proceed to the next exam. You will NOT get credit for saying “I
would do …”
6) As a student patient you are required to appropriately attired as to
enable the examiner to correctly complete the examination with
appropriate exposure
7)The examiner may notify you immediately of a failure should you:
 Fail to adequately expose the body part being examined
 Auscultate through clothing
 Any exam performed without concern for patient safety (i.e.
palpating the abdomen before percussing, improperly using
otoscope etc)\
 Any technique that may significantly decrease the accuracy
of an exam (not auscultating the abdomen before palpation
etc)
Evaluation
Criteria
Communication
Student politely
greets patient and
explains to patient
technique to be
performed
Technique
Student performs
examinations
using a techniques
that assure
accuracy
Thoroughness
Student completes
greater than 90%
of required
examinations
Organization
Student completes
the exam in an
organized fashion
Overall
Evaluation
Unsatisfactory
Satisfactory
Exceeds
Expectations
Cranial Nerve Summative OSCE 2005
A 45 year old female presents to your clinic stating “I think I have had a stroke”. When she looked in the mirror this morning she
noted drooping of her face and inability to close her right eye. She has also drooled coffee all over her nightgown. In addition to the
more comprehensive evaluation that you would perform you are to complete an examination of the cranial nerves. You have ten
minutes to complete this exam.
√ if
THE BEGINNING
Done
Self-Introduction: “Hello, I
am ________. I am a
Physician Assistant
STUDENT and will be part
of the team of people trying
to help you today.”.
Hand-Wash
Nerve
& Fiber type
Test
Smell Test
I
Olfactory
S
Visual Acuity
Visual Fields
II
Optic
S
Fundoscopy
Use RR & LL
Method / DiffDx / Notes
Use to assess student depth of knowledge
Inspect nares, check patency first. Eyes closed, alternate nostrils.
Acceptable: coffee, soap, vanilla, lemon. Do not use irritants like ammonia (stimulates trigeminal
nerve)
DiffDx: tumor, infective/inflammatory, DM neuropathy, Parkinson’s, Huntington’s chorea
Use Schnellen Chart.
Must do best corrected.
Must do left, right and both eyes (OS, OD & OU)
Must screen by confrontation. (stand close, cover opposite eyes – using self as baseline)
Must test each eye individually.
4 Areas: Temporal, Medial, superior and inferior fields screened.
States: “Examining ocular fundi: Looking for optic atrophy, loss of retinal venous pulsation,
papilledema, hemorrhages or exudates, cotton wool spots (retinal infarcts) and nicking.”
Examiner uses their right eye when examining pt’s right, and left when examining left.
Cranial Nerve Summative OSCE 2005
Color Vision
√
Identify 2 colors in the room.
Or Ishihara color plates.
i
f
Done
Pupillary Reaction
III
Oculomotor
A
Extraocular Movements
M
Nystagmus
IV
Trochlear
M
Lid Muscle (observe)
VI
Abducens
S
Corneal reflexes
Facial Sensation
Trigeminal
M
VII
Facial
Hold for 2 seconds: 1-2 beats is normal
Must Test Nystagmus: horizontal, vertical, rotary or mixed
Lid Muscle (observe):
DiffDx: Ptosis (3rd nerve palsy, Horner’s syndrome, myasthenia gravis)
M
coma
exam
V
Size: Equal
Shape: Round
Reaction to Light: Reactive. Check both direct and Consensual. Shine the penlight from the side
so the macula is not directly stimulated and the patient cannot fix on the light and consue reaction
to light with that of accommodation.
(Accommodation: Watch pupils constrict as object is brought in close to bridge of nose.)
PERRLA (Pupils Equal, Round, Reactive to Light & Accommodating.)
EOM: Test all 6 cardinal directions.
DiffDx: “SO4 LR6 “(Superior oblique=4th, Lat. Rectus=6th, remainder=3rd)
M
Jaw Movements
Facial Movements
1. raise both eyebrows
2. frown
3. close eyes tight (pry)
4. show upper & lower
teeth.
5. smile
6. puff out both cheeks
Have pts look to opposite side. lightly touch corneal. do not touch eyelashes or conjunctiva.
Causes blinking of eyelids.
Light Touch: 3 branch areas: Ophthalmic, Maxillary and Mandibular branches.
Sharp vs dull distinction:
(Note: 2nd cervical is sensory for back of head.)
DiffDx: trigeminal neuralgia (“tic Douloureux)
Palpate: temporal & masseter muscles with teeth clench
(Note: Jaw reflex could be tested which also tests sensory component.)
Symmetry, equal range of movement.
DiffDx: Bell’s Palsy
Cranial Nerve Summative OSCE 2005
Taste Test
S
1) Caloric
2) Balance
Anterior 2/3 of tongue.
Following order: anterior to posterior: sweet, salty, sour, bitter. (See CN9)
Finger Rub or Whisper
Start rubbing fingers lightly next to ears. Alternate and ask pt. which ear they hear the slight
rubbing. This is a rough quantitative test for hearing.
(You can slowly move fingers away from ears to see if both equal.)
Unilateral conductive hearing loss.
Place handle of lightly tapped tuning fork at midline skull. Ask which ear is heard louder.
With normal perceptive hearing and no conductive loss, the sounds are equal in the two ears.
When hearing is equal bilaterally, the sound will lateralize to the side of conductive loss. So if hear
in right means conductive lose on the right or perceptive loss on the left.
Touch lightly tapped tuning fork on mastoid (fold ear forward) then in front.
Ask when stops, then hold in front of their ear – ask if hear – if not, you listen.
Conductive hearing loss: BC>AC
Sensorineural hearing loss: AC>BC
Hot – Cold Ear Lavage.
Balance also measured by Cerebellar tests: Romberg, Point-to-point, nystagmus
Gross Hearing test
1. Lateralization
Weber Test
Auditory
S
VIII
2. Air-Bone Conduction
Rinne Test
Vestibulocochlear
S
coma
exam
S
(taste test see 7th CN)
Posterior 1/3 of tongue
IX
Glossopharyngeal
M
Swallowing
(IX difficult to test and seldom necessary. Supplies posterior 1/3 of tongue taste.)
X
Vagus
S
Rise of Palate
Gag Reflex
Ask: say “ah” or to yawn. Should rise centrally.
XI
Spinal
Accessory
M
XII
Hypoglossal
M
1) Shoulder Shrug
2) Neck Movements
Tongue symmetry
Tongue position
Voice and Speech
1) shoulder shrug (Traps)
2) push head against hand laterally (SCM)
Inspect tongue for: 1) Atrophy 2) fasciculations (amyotrophic lateral sclerosis, polio)
V , VII , X , XII
coma
exam
mental
status
exam