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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