Cranial nerves examination – bulbar

Location: You are an final year student in neurology outpatient clinic

Patient: 39 year old patient

Please examine this patient’s bulbar cranial nerves
– Please provide a running commentary whilst you are examining
– After 6 minutes you will be asked a series of questions by the examiner

You are a 39 year old patient who has come to a neurology outpatient clinic. Your examination is normal.

Please feel free to stop the examination if the candidate causes pain or discomfort to yourself.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Clarifies who they are talking to
Asks patient for preferred name

Étique Examination étique
Washes hands
Exposes patient appropriately
Patient positioned sitting
Treats patient with dignity and respect

Inspection General inspection
Other signs of neurological conditions
Look around the bed (e.g. for mobility aids, NBM signs, glasses, hearing aids)

IX, X - Glossopharyngeal, Vagus IX, X - Glossopharyngeal, Vagus
Inspects palate and uvula symmetry
Assesses speech
Assesses cough
Assesses swallow
Says would consider gag reflex and taste (posterior third of tongue)

XI - Accessory XI - Accessory
Inspects for sternocleidomastoid/trapezius muscle wasting
Tests sternocleidomastoid power
Tests trapezius power

XII - Hypoglossal XII - Hypoglossal
Inspects relaxed tongue
Assesses tongue movements/power

Closing Closing examination
Invites patient to get re-dressed
Washes hands

Patient Patient score
Candidate did not cause any pain to patient
Candidate was polite throughout examination

Question How would you differentiate between bulbar and pseudobulbar palsy
Tongue wasting and fasciculations in bulbar palsy (spastic in pseudobulbar palsy)
Absent gag reflex in bulbar palsy (increased/normal in pseudobulbar palsy)
Speech in bulbar palsy = flaccid = indistinct with nasal twang
Speech in pseudobulbar palsy = spastic = monotonous, high- pitched, ‘Donald Duck’ dysarthria

Question What is jugular foramen syndrome?
Paresis of CN 9, 10, 11
Usual cause is a tumour (most commonly glomus tumour)

Submit your answers to get your score.

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