Neurological Examination, Cranial Nerves, Department of General Practice, RCSI

Can you examine this gentleman's cranial nerves please? Certainly. Mr. Smith? Yes. Hello, my name is Dr. Mark Murphy. I'm one of the GPs in the Department of General Practice in the Royal College of Surgeons Ireland. It's nice to meet you. Nice to meet you. I've been asked to examine your cranial nerves. That means examining the nervous system around your eyes and face. I'll ask you a few questions and I'll get you to do a few movements. Okay. Is that okay? Yeah. I'll explain everything as we go along. Are you in any pain or discomfort? No. I might start. The first cranial nerve is the olfactory nerve. Do you have any problem with your sense of smell? No. Okay, that's normal. So I'll move on to the examination of the second cranial nerve, which is the optic nerve. Firstly, I'll examine visual acute. Can I get you to stand up please? That's okay. There are some letters on the wall in front of you. I'll get you to take a step back, one more step back. That's all right. So keeping your glasses on, can I get you to cover your right eye like so? And can I get you to read from the top down? O-A-T-V-X-H-O-T-A-U-H-V-C-A-X-M-V-D-A. That's fine. Thank you very much. I'll get you to do the same with the other eye. O-A-T-V-X-H. Okay, thank you very much. On examination of visual acuity, visual acuity is 6 over 9 in the left eye and 6 over 24 in the right eye using a modified skeleton chart. I might get you to sit down over here, is that all right? So the second part of the optic nerve examination is examination of the visual acuity. That's okay. Sorry, I'm getting a little bit closer to you. Can I get you to look directly straight ahead at my face? Is that okay? Can I get you to cover your right eye with your right hand like so? Okay. Can I get you to look directly at my eye? I'm going to move my finger and can you tell me when you see it? Is that okay? Okay. Can you tell me when you see it moving? Yeah. Can you tell me when it stops, please? No. Okay. Tell me when you see my finger moving again. Tell me when it stops, please. Can I get you to keep your hand where it is? I'm going to move my hand. Tell me when it stops. Okay. And again, can you see my finger moving? There. Tell me when it stops. Perfect. I'm going to get you to swap hands from your left eye. I'm going to repeat those steps and you can look directly at my eye. See my finger moving? Yeah. Tell me when it stops. No. Perfect. Tell me when you see my finger moving. No. Tell me when it stops. No. Again, I'm going to swap my hands. Keep your hand where it is. Keep looking straight ahead. See my finger moving? Yeah. Tell me when it stops. No. Okay. And again, tell me when you see my finger moving. Yeah. Tell me when it stops. Thank you very much. Examination of visual fields is normal. The third part of the optic nerve examination is fundoscopy, which I will not perform. I will now move on to examination of the third, fourth, and sixth cranial nerves, which are often examined together. The first part of the third cranial nerve examination is the light and accommodation response. It examines both the second and third cranial nerves. I'll get you to take your glasses off again, if that's okay. Mr. Smith, for this exam, I'm going to shine a light into your eye. Is that okay? It's okay. Okay. I'll get you to look directly ahead at the wall. Is that all right? Thank you. Examination of the light response, the direct and consensual light response in both eyes is normal. I'll now move on to examination of accommodation. Mr. Smith, can I get you to focus on a point on the firewall far away? Okay. And just keep looking at that, if that's okay. Can I get you to look at my finger? Thank you very much. There was convergence of both eyes with constriction of the pupils, so the accommodation response was normal. I will now complete examination of the third, fourth, and sixth cranial nerve examinations, the ocular motor, the trochlear, and the Duchenne's nerves. Mr. Smith, I'm now going to examine your eye movements. Is that okay? Again, you can keep your head still, but now I want you to move your eyes. Can you look directly at me? I'm going to get you to look at my finger. Is that okay? There was no ptosis or objective sparseness of neutral gaze. Can you tell me if you see double vision at any point? Okay. Do you see double at the moment? No. Just follow my finger, if that's okay. There's no nystagmus on left lateral gaze. There's no nystagmus on right lateral gaze. No double vision? No. Thank you. Examination of the third, fourth, and sixth cranial nerves was normal. I'm now going to examine the fifth cranial nerve, the trigeminal nerve. I will start by examining the sensory branch of the trigeminal nerve. Mr. Smith, I'm going to examine the sensation in your face. Is that okay? It's okay. I'll explain what I'll do. Do you mind opening the top button of your shirt? Okay. That's great. It's okay. I might press the cotton ball in your upper chest, and I'm going to press it. I'll just touch your face. Is that okay? Okay. Can I get you to close your eyes, if that's okay? Can you feel this? Yeah. Can you tell me when you feel it, when it touches your face? Does it feel the same? Feel the same? Same. Yeah. Feel the same? Same. Okay. You can open your eyes. I'm now going to examine a sharper touch, if that's okay. Okay. It won't be painful, but you'll feel a little sharp sensation. Is that okay? So again, I'll start with your chest, and then I'll touch your face. Is that okay? Okay. Can I get you to close your eyes, please? Does that feel sharp or dull? Sure. Can you tell me if you feel a sharp sensation? Yeah. Sharp or dull? Sharp. Sharp or dull? Sharp. Sharp? Sharp. Okay. Thank you very much. Examination of the sensory component of the trigeminal nerve was normal. I'll now move on to examination of the motor component of the trigeminal nerve. So, Mr. Smith, I'm going to get you to, if it's okay, I'm going to have to just examine some muscles in your face. Is that okay? Can I get you to clench your teeth nice and tight like that? The bulk of the masseter muscle and temporalis muscle appear normal. I'm going to examine the pterygoid muscles. Can I get you to open your mouth wide? I'm going to try and close your mouth. Thank you very much. Examination of the motor component of the trigeminal nerve appears normal. I will not examine the corneal response or the jaw-jerk response. I'll now move on to examination of the seventh cranial nerve, the facial nerve, starting with inspection. On inspection, there are no obvious asymmetries in the face. The nasolabial grooves are normal. I'll move on to examine the muscles of the face. Can I get you to look up towards the cedar? Can I get you to close your eyes very tight? I'm going to gently press just above the bow of your eyes. Is that okay? Don't let me open your eyes. Thank you very much. Can I get you to blow out your teeth like me? Perfect. Can I get you to show me all your teeth? Thank you very much. Lastly, can I get you to copy me and do this to me? Perfect. Thank you very much. Examination of the facial nerve was entirely normal. I will now move on to examination of the eighth cranial nerve, the vestibular cochlear nerve. Mr. Smith, do you have any problems with hearing? That's okay. I'm going to assess your hearing. What I'll do is I'm going to press very gently on your ear like so. I'm going to whisper a number into your ear. Is that okay? If you could repeat the number to me, that would be great. Thanks very much. I'm going to press very gently here. Can you repeat this number? 99. Okay. On the far side, can you repeat this number? 74. Thank you very much. Examination of hearing was normal. However, if hearing loss was demonstrated, the Rene test and the Weber test are very useful in elucidating whether or not there was conductive hearing loss or sensorineural hearing loss. Even though there was no hearing loss that was demonstrated, I will now perform the Rene and Weber tests for the purposes of this exam. Mr. Smith, the plate is just behind your ear. Okay. This is the Rene test. Can you tell me if you hear the sound? Yes. Can you tell me when it stops, please? Can you hear the sound? Yes. Thank you. That is the Rene test. I'm now going to move on and examine and perform the Weber test. I'm going to place this in the middle of your forehead. Is that okay? Can you tell me if this sounds equal in both ears? Thank you very much. That is the Weber test. I'll now move on to examination of the 9th and 10th cranial nerves, the glossopharyngeal and the vagus nerve. I'm going to look at your baggage if that's okay. Okay, just go over and wide. Say ah. Ah. Okay. The uvula is in the midline and there is no asymmetry of the platal folds. Thank you very much. I'll now move on to examination of the 11th cranial nerve, the accessory nerve. Mr. Smith, I'll need you to take off your shirt if that's okay. It's okay. Thank you very much. As far as the inspection, the muscle bulk of the sternocleidomastoids and both trapezii muscles appear normal. I'll start examining the power of the trapezius muscles. Can I get you to shrug your shoulders up for me? Is that okay? I'm going to press down. Don't let me push down. That's normal. Thank you very much. I'll now examine the sternocleidomastoids. Do you mind if I put my hand just below your chin? Can I get you to look to the left? Don't let me push you right. I'm feeling the bulk. That's the normal sternocleidomastoid. Can I get you to look to the right? That's a normal sternocleidomastoid bulk and power. Thank you very much. So the accessory nerve examination is normal. Lastly, I'll examine the 12th cranial nerve, the hypoglossal nerve. So firstly, can I get you just to open your mouth? The tongue appears normal with no fasciculations. Can I get you to stick your tongue out? The tongue is in the midline position, which is normal. Can I get you to move your tongue from side to side? Thank you very much. That's normal. So in summary, the 12th cranial nerve examination was normal. That completes the cranial nerve examination. Mr. Smith, thank you very much. You, thank you. Thanks.