OSCE practical 1 tests

CN I tests

-observation of nose externally

-scent test

-internal nose exam

Scent testing steps

1. assess nasal patency 1 nostril at a time

2. close one nostril and slowly bring substance towards patients nose, ask them to identify (asymptomatic first)

3. repeat on other side with different scent

if a patient could not identify the scent when the right nostril was occluded, what is the diagnosis?

CN I lesion on left

2 differentials from nasal patency test

internal and external observations of the nose

internal nasal exam steps

1. tilt pt's head back, use thumb to lift up tip of nose

2. inspect mucosa

3. inspect septum

if you see redness, swelling, and mass in left nostril, what is the diagnosis?

possible CN I lesion or tumor on left

2 differential tests for internal nasal exam

scent testing, external nose exam

CN II tests

-observations of eyes

-visual acuity

-peripheral vision/confrontation

-pupillary light reflex (swinging flashlight)

-ophthalmoscopic exam

if a patient saw 20/20 on their left eye and 20/30 on the right eye, what is the diagnosis?

possible CN 2 lesion on right, cataracts on right, glaucoma on right

visual acuity exam process

1. pt stands 20 ft away from snellen chart (or ten from other)

2.Pt closes one eye (asymptomatic) and read lowest line possible

3. repeat on other side (read opposite way)

4. do both together

2 differential tests for visual acuity

-internal opthalmoscopic exam

-peripheral vision/confrontation

confrontation/peripheral vision exam steps

1. pt stare at distant object and cover one eye

2. instruct them to say "now" when they see the pen (sup, inf, nasally, temporally)

3. repeat on other side

normal exam findings for peripheral field testing

Sup: 50

Nasal: 60

Inf: 70

Lat: 90

when you brought your pen from the temporal view on right during peripheral field testing, the patient said now at 60 degrees. what is the diagnosis?

possible CN 2 pension on right

2 differential tests for peripheral field testing

internal opthalmoscopic, swinging flashlight

swinging flashlight test steps:

1. dim lights

2. pt look at distant object

3. bring light into one eye (asymptomatic first) across bridge of nose to other eye, then back and forth

4. do this a few times

upon bringing light out of your patients right eye, the right eye stayed dilated. what is the diagnosis?

possible CN 2 lesion on right

2 differential tests for swinging flashlight test

internal ophthalmoscopic, visual acuity

opthalmoscopic exam steps

1. dim lights

2. have patient look off at distant object

3. start on asymptomatic side

4. state findings (red reflex, normal cup/dis ratio, macula)

5. perform exam on other eye

2 differential tests for ophthalmoscopic exam

visual acuity, peripheral vision test

pupillary light reflex tests which CN's?

2 and 3

(2&3 direct, 3 indirect)

pupillary light reflex exam process

1. dim lights

2. pt look at distant object and divide eyes with hand

3. shine light 2-3x into asymptomatic side first, looking for a direct response from pupil to constrict

4. shine light into same eye but examine opposite eye for secondary constriction

5. repeat on other eye

upon examination, when shining the light into the right eye, the left eye did not constrict. what is the diagnosis?

possible CN 3 lesion

2 differential tests for pupillary light reflex

visual acuity (CN 2)

accommodation (CN 3)

accommodation tests which CN?

CN 3

accommodation exam process

1. have patient find a distant object

2. pt follows (w/eyes) as another object moves to their nose

3. instruct pt to look at distant object when you say "now"

what are you looking for with accommodation test?

convergence and constriction then divergence and dilation

upon accommodation exam, your patients pupils do not constrict with convergence. What is your diagnosis?

possible CN 3 lesion

2 differential tests for accommodation testing

pupillary light reflex (2&3)

cardinal planes of gaze (3,4,5)

what tests CN 3,4 and 6?

-corneal light reflex

-cardinal planes of gaze

corneal light reflex exam procedure

1. stand in pt's midline

2. pt stare at your glabella

3. shine the light at nasal bridge

4. examine reflexion in both eyes

upon shining the light in your patients eyes, their right eye deviated in, gibing you an asymmetrical finding. What is your diagnosis?

possible CN 6 lesion on right (weak lateral rectus), indicating esotropia in that eye

2 differential tests for corneal light reflex

cardinal planes of gaze, accommodation testing

cardinal planes of gaze exam procedure

1. instruct patient to follow pointer ONLY using their eyes

2. perform in a H or star pattern

3. look for nystagmus/abnormal movement

upon your examination with cardinal planes of gaze, your patient had difficulty lookin down and in with their right eye. what is your diagnosis?

possible CN 4 lesion on left

2 differential tests for cardinal planes of gaze

corneal light reflex, accommodation test

CN 5 exams

-muscles of mastication

-general facial sensation

-general sensation over ant 2/3 of tongue

-jaw jerk reflex

-corneal blink

muscles of mastication exam procedure

1. palpation

2. active ROM

3. active rested ROM

upon your muscles of mastication exam , the patient was weak in lateral deviation to the left. What is your diagnosis?

possible CN 5 motor lesion (V3) on right

2 differential tests for muscles of mastication exam

general sensation over anterior 2/3 of tongue, general facial sensation

general facial sensation exam procedure

1. intro to objects/objectify

2. check to see if they have symptoms

3. have pts close their eyes and differentiate b/w sharp and soft on forearms and point to it

4. test sharp and soft over each division of CN 5

5. test symptomatic side to "normal" division on same side

upon your general facial sensation exam, your patient felt lack of feeling over right forehead. What is your diagnosis?

-R forehead to R maxilla was normal

-L forehead to L maxilla was abnormal

-hyperesthesia of V1 on left

2 differential tests for general facial sensation

general sensation of anterior 2/3 of tongue, muscles of mastication

general sensation over anterior 2/3 of tongue exam procedure

1. touch one side of tongue then other with tongue depressor

2. ask pt if they can feel and if it feel the same bilaterally

if your patient has a lack of sensation on the right tongue, what is your diagnosis?

right CN 5 lesion

2 differential tests for general sensation over ant 2/3 of tongue

general facial sensation, muscles of mastication

jaw jerk reflex exam procedure

1. instruct pt to close their eyes and open their mouth halfway with jaw relaxed

2. place one finger on pts chin and gently tap your finger with reflex hammer

(looking for slight upward jerk of jaw)

upon examination of your patients jaw jerk reflex, pts jaw had an exaggerated flex. what is your diagnosis?

possible UMNL of CN5

(exaggerated -> UMNL ; diminished -> LMNL)

2 differential tests for jaw jerk reflex

general sensation over ant 2/3 of tongue, general facial sensation

corneal blink reflex tests which CN?

5 and 7

corneal blink reflex exam procedure

1. tell pt to look away

2. gently touch cornea of asymptomatic eye first (should get blinking in both eyes ; 5&7 working in eye that was touched, 7 in other eye)

5 = sensory

7 = motor (blink)

upon your examination of corneal blink reflex, your noticed the pts R eye is normal, but did not respond to the cotton swap on cornea in L eye. what is your diagnosis?

CN 5 lesion on left (lack of sensory info)

2 differential tests for corneal blink reflex

general sensation of face (5), muscles of facial expression (7)

tests for CN 7

-muscles of mastication

-general taste over ant 2/3 of tongue

muscles of facial expression exam procedure

ask patient to: smile, frown, puff cheeks, look up (wrinkle forehead)

upon examination of muscles of facial expression, all of the muscles on the patients left side were weak. what is your diagnosis?

bells palsy on left (LMNL)

is stroke UMN or LMN? ipsilateral or contralateral?

UMN contralateral

is bells palsy UMN or LMN? ipsilateral or contralateral?

LMN ipsilateral

2 differential tests for muscles of facial expression

general taste over anterior 2/3 of tongue, corneal blink

tests for CN VIII

-otoscopic exam

-observation of external ear

-weber test

-rinne test

-caloric irrigation

-finger rustle

otoscopic exam procedure

1. pull pinna posterior and superior

2. use fingers to stabilize on pts face

3. gently insert the speculum into pts ear

4. observe and state findings

2 differential tests for otoscopic exam

observation of internal ear, finger rustle

weber test exam procedure

1. strike the 512 tuning fork and place it on the pts head

2. ask pt if it is louder to one side or the same in both

abnormal weber test

lateralization

-air conduction if on side of lateralization

-sensorineural loss if on other side

if your pt heard the weber test better in their right ear, what is your diagnosis?

either conductive/obstructive in R ear or sensorineural in L

2 differential tests for weber test

rinne to confirm finding, otoscopic exam, finger rustle exam

rinne test exam procedure

1. strike the 512 tuning fork and place it on pts mastoid, time it, and have them tell you when they can't hear it anymore

2. quickly move it to front of pts ear and have them tell you again when you can't hear it

what are your expected findings with rinne test?

front/EAM should be 2x as long as on mastoid

in webers, your pt heard it better in the L ear. On rinne, the R ear had 10 sec heard on mastoid and 25 in front of EAM. in L ear, mastoid was heard for 8 seconds and EAM was heard for 10. What is your diagnosis?

conductive/obstructive hearing loss in L ear

2 differential tests for rinne test

webers, finger rustle

Tests for CN 9 and 10

gag reflex, say AHHHHH, Kuh-la-mi, taste on posterior 1/3 of tongue

you tell your pt to say "AHHHH" and you notice the L palate is lower than R and uvula deviates to R. what is your diagnosis?

L CN 9 or 10 lesion

2 differential test for say "AHHHHH"

gag reflex, kuh-la-mi

when you tell your pt to say "kuh-la-me", you notice they had slurred speech upon attempt. what is your diagnosis?

possible CN 9 and 10 lesion and/or dysarthria

2 differential tests for "kuh-la-mi"

say AHHHH, gag reflex

CN 11 test

SCM and trap test

SCM and trap test exam procedure

1. test traps: have pt shrug/elevate shoulders up then push them down while they resist

2. test SCM: if symptoms are on R side, turn head to right first against resistance (tests L SCM)

upon your SCM and Trap test exam, you notice the pt had weakened right rotation. what is your diagnosis?

possible LMNL to left SCM

2 differential test for SCM and trap test

say AHHHH, gag reflex

(any 9,10,12 exam because of their proximity to medulla)

CN 12 tests

-stick tongue out

-tongue in cheek

stick tongue out exam procedure

have pt stick tongue out (does it deviate?)

-will deviate to weak side

upon sticking their tongue out, it deviated to pts right side and looked atrophied. what is your diagnosis?

LMNL right CN 12 or UMNL left CN 12

2 differential tests for stick tongue out test

tongue in cheek, trap and SCM test

(any 9,10,11 exam)

Tongue in cheek exam procedure

1. have pt stick tongue into cheek (if symptoms are on R side have them stick tongue into R cheek)

2. push against their tongue assessing its strength

3. repeat on other side

if your patient could not resist doctor pressure when pushing tongue into left cheek, what is your diagnosis?

possible LMNL of R CN 12 or LMNL of L CN 12

2 differential test for tongue in cheek test

stick out tongue, trap and SCM test (any 9,10,11 tests)

Vertebrobasilar artery insufficiency/stenosis exams

-VBA functional maneuver

-barre-loui

-dekleyn test

VBA functional maneuver exam procedure

(DO FIRST)

1. auscultate carotid and subclavian with both diaphragm and bell

2. palpate carotid and subclavian

3. have pt rotate and extend neck and count backward from 20 (look towards asymptomatic side first) ; look for nystagmus

4. repeat on other side

while performing the VBA functional maneuver test, upon rotation and extension, your pt began to feel dizzy and nauseous. What is your diagnosis?

indicates VBAI

2 differentiating tests for VBA functional maneuver

barre-loui, dekleyn test

barre-loui exam procedure

1. pt seated and instructed to turn their head R then L

2. increase pace for about 5-6 times each side

you didn't find any abnormalities with barre-loui test, what do you have to say for your diagnosis?

normal test ; but still have to say 2 other exams

(if it was abnormal, I would do ______ and _____ to confirm normal finding)

2 differential test for barre-loui

VBA functional maneuver, dekleyn test

dekleyn test procedure

1. pt supine, extend head off table and rotate to one side

2. pt count backwards from 20 (watch for nystagmus)

3. repeat on other side

your pt reported dizziness and blurred vision with dekleyn test. what is your diagnosis?

indicates VBAI

2 differential tests for dekleyn test

VBA functional maneuver, barre-loui

what is a test to rule out cervicogenic vertigo?

swivel chair test

swivel chair test procedure

1. pt sits in swivel chair w/ doctor supporting their head

2. have them rotate from side to side a few times (head should stay in place)

if your patient reports dizziness with the swivel chair test, what is your diagnosis?

cervicogenic vertigo

2 differential tests for cervicogenic vertigo

VBA functional maneuver, barre-loui