Cranial Nerve Examination checklist

WIPPER and the Intro

• Introduce yourself and shake hands
• Washing of hands and appropriate hand hygiene
• Asking for permission
• Ensuring the room’s privacy
• Ensuring the environmental warmth and good lighting conditions
• Asking for appropriate exposure (Head and neck)
• Asking the patient to be in the appropriate position (Sitting on a chair)
• Relocating to the right side of the patient
• Asking for a chaperon
• “I have all of my equipment’s”

Olfactory Nerve Examination (Useless)

• Check the nasal passage
• Ask the patient to close his eyes
• Close one nostril to test the other
• Ask the patient to smell (Use scratch and sniff test cards from UPSIT test)
• Close the other nostril and repeat

Optic Nerve Examination

Inspection

• Comment on no head tilt
• Comment on no facial asymmetry
• Comment on no proptosis
• Comment on no lid retraction
• Do lid lag test, stand up and ask the patient to follow your finger, move it up and back, bottom and back, and comment on no lid lag

Palpation

• Do the usuals for palpation
• Comment on no tenderness over the eyes

Tests to Mention

• “I will assess visual acuity using Snellen’s chart”
• “I will assess color vision using Isihara plates”
• “I will assess macular sparing using Amsler’s grid”
• “I will do fundoscopy examination for things like optic disk examination, papilledema etc.”

Pupillary Reflexes Tests

• Dim the room and check the pupils’ size for anisocorea
• Ask the patient to fixate his eye on a distant point
• Get your torch, slide it horizontally to one eye, notice “Direct” reflex, then look at the other eye for “Indirect/consensual” reflex
• Comment on intact direct and indirect pupillary reflexes
• While patient is fixating, put your finger ~15cm in front, ask him to focus on it and notice “Convergence”
• Comment on normal accommodation reflex

Visual Field Tests

• Ask the patient to look at your eyes
• Hold 1 hand at full extent, wiggle fingers and ask if patient sees movement
• Test at 2, 4, 8 and 10 o’clock positions
• Comment no homonymous visual field defect
• For sensory inattention: hold both hands at 2 and 10 o’clock, wiggle one then both
• Comment no sensory inattention

Peripheral Visual Fields (one eye at a time)

• Perform 1 eye closing maneuver
• Ask patient to look at your eyes
• Test each quadrant (2,4,8,10 o’clock) with finger wiggling
• Test the other eye
• Comment no peripheral visual field defects

Color Desaturation

• Show red object to ensure patient sees it red
• Perform 1 eye closing maneuver
• Place red object in front of open eye, ask about color
• Test the other eye
• Comment “No red desaturation”

Central Visual Field

• Perform 1 eye closing maneuver
• Ask patient to look at your eyes
• Move red object from side to center until color is noticed
• Test the other eye
• Comment no central visual field defects

Blind Spot

• Perform 1 eye closing maneuver
• Ask patient to look at your eyes
• Move red object horizontally until it disappears
• Test the other eye
• Comment on normal blind spot size

Ocular Movement Nerves (3rd, 4th, 6th)

• Ask patient to fix head and only move eyeballs following your finger
• Draw H shape, observe eye movements
• Ask about diplopia and its features if present
• Comment on no nystagmus, no diplopia, full range of motion

Trigeminal Nerve

Sensory

• Test light touch on V1,V2,V3 areas bilaterally with cotton-wool
• Repeat with neural tip for superficial pain
• Mention testing general sensation on anterior 2/3 of tongue
• Comment on intact symmetrical sensation

Motor

• Palpate/inspect temporalis for wasting
• Ask patient to clench teeth, check masseters
• Ask patient to open mouth, inspect for jaw deviation
• Comment no muscle wasting, good bulk, no deviation

Reflexes

• For jaw reflex: place finger between lower lip/chin, percuss with hammer
• Comment on normal jaw reflex
• Mention testing corneal reflex

Facial Nerve

Motor

• Ask patient to raise eyebrows, assess symmetry (frontalis)
• Comment symmetrical wrinkles
• Ask patient to forcefully close eyes against resistance
• Comment normal power of orbicularis oculi
• Ask patient to “Blow out your cheeks and don’t let me deflate them”
• Comment normal power of buccinator/orbicularis oris
• Ask patient to show teeth (smile)
• Comment symmetry and no mouth angle deviation

Sensory

• Test touch sensation behind ear
• Mention testing taste on anterior 2/3 of tongue
• Mention corneal reflex
• Ask about hearing changes (stapedius muscle)

Vestibulocochlear Nerve

Hearing Tests

• Stand behind patient, ensure normal hearing first
• Close one ear, whisper at 60cm, ask patient to repeat
• If needed, whisper at 15cm

Weber’s Test

• Tap 512Hz fork, place on forehead midline
• Ask if sound is louder in any ear
• Comment negative Weber’s test (no lateralization)

Rinne’s Test

• Tap 512Hz fork, place on mastoid prominence
• Ask patient to signal when sound stops
• Move fork near ear, ask if sound returns
• Comment positive Rinne’s test (air>bone conduction)

Glossopharyngeal and Vagus Nerves

• Ask patient to talk, note no dysphonia/dysarthria
• Ask patient to say “aah”, check uvula
• Comment no uvula deviation
• Ask patient to puff cheeks, listen for nasal regurgitation
• Comment no nasal regurgitation
• Ask patient to cough (assess for bovine cough)
• Mention testing gag reflex
• Mention giving water to assess swallowing
• Mention testing taste on posterior 1/3 of tongue

Accessory Nerve

• Inspect SCM and trapezius
• Comment no wasting/asymmetry in trapezius
• Palpate both muscles for bulk
• Comment normal bulk
• Test trapezius power: shrug shoulders against resistance
• Comment normal trapezius power
• Test SCM power: turn head against resistance
• Test other SCM
• Test bilateral SCM: look down against chin resistance
• Comment normal SCM power

Hypoglossal Nerve

• Ask patient to open mouth, inspect tongue
• Comment no wasting/fasciculations
• Ask patient to protrude tongue, check deviation
• Comment no deviation/fasciculations
• Ask patient to move tongue side-to-side quickly
• Comment normal movement
• Ask patient to press tongue against cheek, assess power
• Comment normal power
• Assess speech with “Yellow lorry” etc.
• Comment normal speech
• Mention testing swallowing

THE END