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

Patient: 60 year old patient

Please examine this patient’s 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 60 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)

I - Olfactory I - Olfactory
Ask patient if they have noticed any change in smell

II - Optic II - Optic
Acuity - distant vision with Snellen chart
Acuity - near vision
Acuity - says would test colour vision with ishiharachart
Fields - tests visual fields by confrontation
Fields - inattention
Fields - tests/offers to test blind spots
Reflexes - accommodation reflex
Reflexes - direct and consensual papillary reflexes
Reflexes - swinging light test
Ophthalmoscopy - says they would also consider fundoscopy

III, IV, VI - Oculomotor, Trochlear, Abducens III, IV, VI - oculomotor, trochlear, abducens
Inspects for strabismus, ptosis
H-test performed correctly

V - Trigeminal V - Trigeminal
Inspect for temporalis/masseter muscle wasting
Tests sensation over ophthalmic, maxillary and mandibular distributions of the trigeminal nerve
Temporalis and masseter muscle power
Says they would consider testing corneal reflex and jaw jerk

VII - Facial VII - Facial
Inspect for facial asymmetry
Test facial motor function
Says they would consider testing taste (anterior two thirds tongue)

VIII - Vestibulocochlear VIII - Vestibulocochlear
Crude hearing test
Weber’s test
Rinne’s test

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 What are the nerves involved in the gag reflex?
Afferent = CN 9
Efferent = CN 10

Question Describe the difference between afferent and efferent pupillary defects
Afferent defect = pupils are symmetrical but when light is shone in the affected eye, neither pupil constricts = CN2 (optic nerve) lesion
Efferent defect = affected pupil is persistently dilated, whilst other is reactive to light being shone in either eye = CN3 lesion

Submit your answers to get your score.

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