NMS OSCE 1

Olfactory Function: tests CN I

1. observe external nose while patient is seated

2. Test each side with different scent (asymptomatic side first)

   1. occlude opposite nostril and ask patient to identify the odor, this tests the contralateral side (ie. left nostril tests right side)

3. internal nose exam (asymptomatic side first)

4. ask patient if they have pain, if yes ask where and to point to it

Confrontation Test (peripheral vision): tests CN II

1. Have patient seated, stare at a point behind/at you and cover 1 eye

2. Ask patient to tell you when they first see red tip of object

3. bring instrument into patient’s visual field testing superior (50º), nasal (60º), inferior (70º), and temporal (90º) fields of vision

4. Ask patient if they have pain, if yes ask where and to point to it

Pupillary Light Reflex: tests CN II & III directly and III indirectly

1. patient seated with lights dimmed, place 1 hand by nose to ‘divide’ eyes

2. shine light into asymptomatic eye

   1. note amount/speed of pupillary constriction in tested pupil (II, III) and opposite pupil (III) with light, note dilation when light is removed

   2. CN III lesion will affect direct & indirect response on involved side but direct & indirect will be intact on opposite side

   3. constriction from 4mm to 1mm is considered normal

3. repeat process 3-4 times in each eye

4. Ask patient if they have pain, if yes ask where and to point to it

Cardinal fields of gaze: tests CN III, IV, VI

1. patient seated, instruct patient to hold head still and have eyes follow object

2. perform H or * pattern

   1. note any nystagmus or visual signs of difficulty

      1. difficulty looking down & in = ipsilateral CN IV lesion

      2. unable to laterally deviate eye = ipsilateral CN VI lesion

      3. nystagmus = cerebellar lesion ipsilateral to eye

3. Ask patient if they have pain, if yes ask where and to point to it

Accommodation: tests CN III

1. patient seated and instructed to look at tip of red pen as it moves toward them until told the word ‘now’ in which patient then looks at far object

2. Bring pen towards patient and 3 things should occur:

   1. convergence of eyes

   2. constriction of pupils

   3. thickening of lens

3. say word ‘now’ and watch as patient focuses on far object

   1. eyes should diverge

   2. pupils should dilate

4. Ask patient if they have pain/double vision, if yes ask where and to point to it

Ophthalmoscopic/fundiscopic exam: tests CN II

1. patient seated and lights dimmed to allow for pupil dilation

2. have patient focus on spot on wall directly over your shoulder

3. examine asymptomatic eye first (their right with your right and vice versa)

   1. stabilize yourself against patient by pulling eyebrow up & lateral

   2. find red light reflex and approach eye gradually

   3. visualize structures (cup, disc, vasculature, color of retina

   4. have patient look into light or lean medial to see macula

4. Ask patient if they have pain, if yes ask where and to point to it

Corneal light reflex: tests CN III, IV, VI

1. patient seated and focusing on your forehead

2. bring light source superior to head and slowly lower light until visible in cornea of patient’s eyes

   1. note position of both eyes (11 & 1 o’clock)

      1. eye deviated down & out = ipsilateral CN III lesion

      2. eye deviated up and out = ipsilateral CN IV lesion

      3. eye deviated medially = ipsilateral CN VI lesion

      4. eye deviated out (exotropic) & large pupil = CN III lesion

3. Ask patient if they have pain, if yes ask where and to point to it

Swingling flashlight test: tests CN II

1. patient seated

2. shine light in 1 eye for 1-2 sec then rapidly swing to other eye & repeat back and forth

3. both pupils should constrict strongly when light is shining into them and dilate slightly when light is swinging over bridge of nose

   1. an affected side gives you illusion of apparent dilation but really is constricting & returning to resting state slower than other eye & doesn’t detect new light shining into it to constrict again

      1. indicates retinal or CN II lesion with sensory arc decreasing amount of pupillary motor response

4. Ask patient if they have pain, if yes ask where and to point to it

Trigeminal nerve: tests V1, V2, V3 of CN V

1. patient seated, inspect muscle volume & strength, observe for any obvious atrophy

2. palpate muscles of mastication

   1. place fingers bilaterally along anterior aspect of Masseter then over temporalis and ask patient to clench their jaw

   2. feel for symmetry

3. perform active ROM (ask patient to move jaw open, close, deviate left & right)

4. perform active resisted ROM

5. Ask patient if they have pain, if yes ask where and to point to it and if it radiates

Corneal blink reflex: tests CN V (afferent) & CN VII (efferent)

1. patient seated

2. touch clean wisp of cotton to lateral cornea

   1. CN V sensory arc with CN VII normally causes eye to blink

      1. if patient doesn’t blink CN V lesion or central connection lesion

3. Ask patient if they have pain, if yes ask where and to point to it

Sensory exam of face (light touch and pain (sharp vs dull)): tests afferent CN V

1. patient seated, introduce sharp & light touch stimuli with patient’s eyes open, randomly apply control baseline touches of both stimuli in area not being tested

2. touch patient 2-3x randomly alternating with sharp and light stimuli and have patient point to where they felt it in all sections (V1-V3)

3. compare side to side with light touch then sharp touch

   1. areas of hyper/hypoesthesia should be compared to sections you know has intact sensory function

   2. determine which section of CN V is affected by their dermatomal patterns

4. perform jaw jerk reflex

   1. patient closes eyes, place index finger over chin and hold mouth open halfway with jaw relaxed, tap finger with reflex hammer

      1. response should be minimal upwards jerk of jaw

5. Ask patient if they have pain, if yes ask where and to point to it

Facial nerve motor exam: tests CN VII

1. patient seated and asked to smile, look up, frown, clench eyes, and puff cheeks to check muscles of face

   1. check for symmetry of movement characteristics

      1. nasolabial folds (smile), forehaed wrinkles (look up), frown shape

   2. tell them to puff cheeks and resist you

2. check taste (anterior 2/3 of tongue)

3. Ask patient if they have pain, if yes ask where and to point to it

Taste evaluation: tests CN VII

1. patient seated, have rinse mouth with water, close their eyes, and protrude tongue

2. drop small amount of sweet/sour/salty substance on superior lateral surface of tongue and instruct patient to identify substance without bringing tongue back into mouth

   1. give instructions beforehand to hold up 1 finger for sweet and 2 fingers for salty

   2. rinse mouth thoroughly and repeat test on other lateral side of tongue

3. Ask patient if they have pain, if yes ask where and to point to it

Weber test: tests CN VIII

1. patient seated

2. strike and place 512 tuning fork on vertex of patient’s skull, ask if it lateralizes to 1 side or sounds the same in both ears

   1. should hear it equally bilaterally if not it will lateralize to either the:

      1. ipsilateral side of air conduction loss

      2. contralateral side of sensorineural loss

3. Ask patient if they have pain, if yes ask where and to point to it

Rinne test: tests CN VIII

1. patient seated, instructed to tell the intern to say the word ‘now’ when they can no longer hear the tuning fork and to repeat it after tuning fork moves

2. strike & place 512 tuning fork on patient’s mastoid process, counting until patient says the word ‘now’

3. when patient says ‘now’ move tuning fork to side of ear and count until patient says ‘now’ or until 2x the time of bone conduction is reached

4. air conduction should be 2x bone conduction

   1. if rinne’s test is 1:1 on side of lateralization and 2:1 on contralateral side = ipsilateral air conduction loss

   2. If rinne’s test is 2:1 on side of lateralization and 1:1 on contralateral side = contralateral sensorineural loss

5. Ask patient if they have pain, if yes ask where and to point to it

Otoscopic exam of internal ear: tests CN VIII

1. patient seated

2. in adult patient pull ear back and up, child patient pull ear back and down

3. note characteristics of inside ear

4. Ask patient if they have pain, if yes ask where and to point to it

Barre-Lieou Test: tests vertebrobasilar artery insufficiency (VBI)

1. patient is seated

2. ask patient to slowly rotate head side to side

   1. looking for vertigo, nystagmus, nausea, and visual changes

      1. any/all indicate vertebrobasilar artery insufficiency

3. Ask patient if they have pain, if yes ask where and to point to it

Swivel chair test: tests for VBI

1. patient seated, doctor stabilizes patient’s head (takes out vestibular system)

2. have patient rotate body side to side

   1. if dizziness occurs = cervicogenic vertigo

3. Ask patient if they have pain, if yes ask where and to point to it

Caloric Irrigation: tests CN VIII (vestibular) “COWS” = Cold Opposite Warm Same

1. patient seated

2. add small amount of cold water into ear

   1. eyes should show nystagmus away from side of irrigation

3. add small amount of warm water into ear

   1. eyes should show nystagmus towards side of irrigation

4. perform bilaterally

5. Ask patient if they have pain, if yes ask where and to point to it

Glossopharyngeal test: tests CN IX

1. patient seated and asked to say ‘ahhhhhh’

   1. visualize back of throat to assess elevation of soft palate and pahryngeal arches

2. gag reflex (posterior 1/3 of tongue) should occur when back of tongue touched with tongue depressor

3. check phonation by having patient say ‘kuh, la, mi’

4. check taste of posterior 1/3 of tongue using bitter substance

5. Ask patient if they have pain, if yes ask where and to point to it

Accessory nerve test: tests CN XI (SCM & trap)

1. patient seated and instructed to

2. patient seated and instructed to

   1. actively elevate shoulders, laterally flex neck to right then left, and rotate cervical spine to right then left

   2. repeat movement but this time with resistance

3. Ask patient if they have pain, if yes ask where and to point to it

Hypoglossal nerve test: tests CN XII

1. patient seated, instructed to stick out tongue

   1. look for an deviation, atrophy, or fasciculations

2. patient instructed to perform tongue in cheek without resistance then to resist doctor pushing in on it

3. repeat on other side

4. Ask patient if they have pain, if yes ask where and to point to it

vertebrobasilar artery insufficiency exam: tests for VBI

1. patient seated

2. doctor auscultates carotid & subclavian arteries for bruits (diaphragm & bell)

3. doctor palpates carotid & subclavian arteries for bruits

4. if no bruits and no pulsations present:

   1. instruct patient to rotate and hyperextend head to one side then other and count back from 20

      1. difficulty/confusion = VBI

5. Ask patient if they have pain, if yes ask where and to point to it

De Kleyn’s test: tests for VBI

1. patient in supine position with head extending off end of table

2. patient rotates and hyperextends neck to one side and hold position for 15-45 seconds

3. repeat on other side

4. Ask patient if they have pain, if yes ask where and to point to it

Cerebellar & proprioception abnormal findings:

• dysmetria: inaccuracy measuring distance ex- past pointing extremities

  • eyes open & closed indicates cerebellar and/or vestibular deficit

  • eyes closed only indicates dorsal columns deficit

• dyssyneriga: in-coordinate movement ex- falling

  • eyes open & closed indicates cerebellar and/or vestibular deficit

  • eyes closed only indicates dorsal columns deficit

Romberg’s test: tests cerebellar proprioception

1. have patient remove shoes & socks keeping feet close together but not touching looking straight ahead first with eyes open then eyes closed

   1. stand near patient and watch for swaying or loss of balance

2. Ask patient if they have pain, if yes ask where and to point to it

3. abnormal findings: if patient takes a step or falls

Hopping on 1 foot: tests entire nervous system

1. have patient remove sock and shoes then stand on 1 foot and hop

2. perform first eyes open then closed bilaterally

   1. requires intact function of nervous system (motor and sensory tracts, cerebellum, basal ganglia, and peripheral nerves)

3. Ask patient if they have pain

4. abnormal findings: if patient takes a step or falls

Squatting on 1 foot: tests cerebellum & proprioception

1. have patient stand then remove shoes and socks

2. remain close to patient and ask them to stand on 1 foot and squat eyes open then eyes closed bilaterally

3. Ask patient if they have pain

4. abnormal findings: if patient takes a step or falls

Finger to Nose test: tests cerebellar proprioception

1. ask patient to stand (or sit) with arms stretched out to the side

2. bring tip of index finger through wide arc and touch tip of nose eyes open then closed, perform slowly then rapidly

   1. should see smooth and accurate movement

3. Abnormal findings: dyssynergia, dysmetria

   1. past pointing eyes open ONLY = ipsilateral cerebellar lesion

   2. past pointing eyes open & closed = dorsal columns deficit

finger to finger test: cerebellar proprioception

1. ask patient to stand with arms stretched out to side and bring tips of index fingers through wide arc to touch in midline of body

2. perform eyes open then closed

3. Ask patient if they have pain, if yes ask where and to point to it

4. Abnormal findings: dyssynergia, dysmetria

   1. past pointing eyes open ONLY = ipsilateral cerebellar lesion

   2. past pointing eyes open & closed = dorsal columns deficit

finger to nose to finger test: cerebellar proprioception

1. patient sitting or standing, ask to touch index finger to tip of nose then touch examiners finger then nose again as examiner moves their finger around

2. perform bilaterally eyes open only

3. Ask patient if they have pain, if yes ask where and to point to it

4. Abnormal findings: dyssynergia, dysmetria

   1. past pointing = ipsilateral cerebellar lesion

heel to shin test: cerebellar proprioception

1. patient lying supine (or standing) and instructed to approximate asymptomatic side’s heel to opposite shin and drag it superior to inferior over top of foot

2. perform eyes open then closed bilaterally

3. Ask patient if they have pain, if yes ask where and to point to it

4. abnormal findings: inability to perform actions properly

   1. indicates a possible cerebellar dysfunction

diadochokinesia (rapid alternating movements): cerebellar proprioception

1. patient seated and instructed to alternately supinate and pronate hands on lap, touch tip of thumb with each finger rapidly in sequence, tap foot steadily against floor

2. perform all with eyes open and closed bilaterally

   1. should perform all actions properly and smoothly

3. Ask patient if they have pain, if yes ask where and to point to it

4. Dysdiadochokinesia: inability to perform actions properly

   1. indicates a possible cerebellar dysfunction

Holmes rebound phenomenon: tests cerebellar proprioception

1. patient seated, holding arms adducted at shoulder and flexed at elbow with forearm supinated and fist firmly clenched

2. patient asked to contract flexors of forearm against doctors resistance at wrist

3. suddenly release resistance

   1. patient should stop their arm before they hit their face (hold hand up just in case)

4. perform eyes open & closed bilaterally

5. Ask patient if they have pain, if yes ask where and to point to it

Tandem gait test: tests cerebellar proprioception

1. ask patient to stand and remove shoes and socks

2. patient walks in straight line placing heel of 1 foot directly in front of opposite toes for 4-5 steps

3. perform eyes open and closed bilaterally

4. Ask patient if they have pain, if yes ask where and to point to it

5. abnormal findings: if patient takes a step or falls

Joint position upper or lower extremities): cerebellar proprioception

1. patient seated and asked to remove shoes and socks if testing LE

2. examine digits of hand/foot by stabilizing hand/foot and grabbing a single digit from sides and flexing or extending digit without placing any pressure on top or bottom of digit

3. ask patient to say whether you are moving digit up or down

4. Ask patient if they have pain, if yes ask where and to point to it

Abadie’s sign: deep pain test

1. position patient seated or supine and pinch achilles tendon

2. Ask patient if they have pain

3. perform bilaterally asymptomatic side first

Pitre’s sign: deep pain test

1. position patient seated or supine and pinch testicles

2. Ask patient if they have pain

3. perform bilaterally asymptomatic side first

Biernacki’s sign: deep pain test

1. position patient seated or supine and tap along medial aspect of elbow-cubital tunnel

2. Ask patient if they have pain

3. perform bilaterally asymptomatic side first

Multimodal-association cortex exam abnormal/decreased findings indicate a contralateral parietal lobe association cortex lesion

Sterognosis: Multimodal-association cortex exam

1. have patient seated or supine with eyes closed and place common object in hand

2. ask patient to identify object in their hand

3. perform bilaterally asymptomatic side first

4. ask patient if they have pain

5. findings example:

   1. sterognosis was decreased on right (the sensory exam involving the dermatomes and peripheral nerves were found to be intact). Therefore the patient has a suspected left parietal lobe ‘association cortex’ lesion

Barognosis: Multimodal-association cortex exam

1. have patient seated or supine with eyes closed and ask them to compare the weights of 2 similarly shaped objects stating which is heavier

2. perform bilaterally asymptomatic side first

3. ask patient if they have pain

4. findings example:

   1. barognosis was decreased on left (the sensory exam involving the dermatomes and peripheral nerves were found to be intact). Therefore the patient has a suspected right parietal lobe ‘association cortex’ lesion

Topognosis: Multimodal-association cortex exam

1. have patient seated or supine with eyes closed and touch them somewhere on the skin and have them point to the area that you touched

2. perform bilaterally asymptomatic side first

3. ask patient if they have pain

4. findings example:

   1. topognosis was decreased on right (the sensory exam involving the dermatomes and peripheral nerves were found to be intact). Therefore the patient has a suspected left parietal lobe ‘association cortex’ lesion

Graphognosis: Multimodal-association cortex exam

1. have patient seated or supine with eyes closed and draw a letter or number on palmar aspect of hand and ask patient to identify the letter/number you drew

2. perform bilaterally asymptomatic side first (switch from letter to number or vice versa)

3. ask patient if they have pain

4. findings example:

   1. graphognosis was decreased on left (the sensory exam involving the dermatomes and peripheral nerves were found to be intact). Therefore the patient has a suspected right parietal lobe ‘association cortex’ lesion

Somatognosis: Multimodal-association cortex exam

1. have patient seated or supine with eyes closed and take their hand and touch their own arm with their index finger and ask 'is this your own arm?’

2. place your forearm next to patient to touch their own arm with their finger

3. perform bilaterally asymptomatic side first

4. ask patient if they have pain

5. findings example:

   1. somatognosis was decreased on right (the sensory exam involving the dermatomes and peripheral nerves were found to be intact). Therefore the patient has a suspected left parietal lobe ‘association cortex’ lesion

2 point discrimination: Multimodal-association cortex exam

1. have patient seated or supine with eyes closed, touch patient with sharp object stimuli and ask if they can identify if they are being touched with 1 or 2 stimuli

   1. start stimuli far from each other and get closer each time

2. perform bilaterally asymptomatic side first

3. ask patient if they have pain

4. findings example:

   1. sterognosis was decreased on right (the sensory exam involving the dermatomes and peripheral nerves were found to be intact). Therefore the patient has a suspected left parietal lobe ‘association cortex’ lesion