General Observations
Check visually from the end of the bed:
• Muscle wasting, fasciculaitons, or tremor
• Facial asymmetry or loss of expression
• Ptosis
• Strabismus (misaligned eyes)
• Salivation
• Obvious discomfort or pain |
CN 1 Olfactory
Changes in taste or smell recently? |
Explored with a smell testing kit |
Tested positive for Covid-19 previously? |
CN 2 Optic
Visual Acuity |
Examined using a Snellen chart or text held at arms length |
Visual Fields |
Examiner and patient close one eye.
Examiner moves an object closer to the centre of the midline.
Patient remarks when it enters their field of view. |
Fundoscopy |
Not required in DEM2 |
Light Reflexes |
Direct light reflex
(Look in the same eye as the light)
Consensual light reflex
(Look at the opposite eye to the light) |
Accommodation |
Pupils constrict as object is brought closer |
Patient should wear glasses if normally worn.
Offer to check near, far, central, and colour vision.
Light Reflexes:
• Sensory -> CN2
• Motor -> CN3
CN 3,4,6 Oculomotor, Trochlear, Abducens
Ocular Movements |
Patient follows tip of pen in a H shape
Should be tested to all extremes of eye movement |
LR6SO4(3)
Lateral Rectus => CN6
• Eye will not abduct normally, double vision, horizontally displaced
Superior oblique => CN4
• Double vision with oblique displacement of images, left palsy -> occurs when looking to the right, etc.
All other extraocular muscles => CN3
• In full palsy pupil will be dilated and deviate downwards and outwards
• Also innervates levator palpebrae superioris => Ptosis in palsy
CN 5 Trigeminal
Sensory: |
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Touch Response |
Touch opthalmic, maxillary and mandibular regions of the face with cotton whool, compare sensation on both sides.
Show the patient what it feels like first by touching to a central point (chest)
Offer to repeat with a pointed object |
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Corneal Reflex |
Omitted if a lesion is not suspected
Touch lateral region of cornea with a damp piece of cotton wool => Bilateral blink response |
Motor: |
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Muscles of Mastication |
Patient clenches jaw shut, examiner palpates temporlais, and masseter.
Patient opens mouth, examiner attempts to close it, patient should be able to resist.
Patient opens mouth and move jaw from side to side => Jaw will deviate to the side of the weak pterygoid. |
CN 7 Facial
Patient raises eyebrows |
Symmetrical wrinkling of forehead due to contraction of the frontalis muscle |
Patient squeezes eyes tightly shut |
Examiner attempts to open eyes using thumbs
Tests orbicularis oculi. |
Patient smiles |
Symmetrical smile and equal action of teh orbicularis muscle |
Patient blows up cheeks |
Checks buccinator muscle
If cheeks are pressed lightly by examiner no air should escape |
Do a quick general inspection of the face before starting, check for drooling, facial asymmetry, etc.
CN 8 Vestibulocochlear
Simple Hearing Test |
Cover one ear and whisper a number in the other, ask the patient to repeat back to you.
Repeat for both ears |
Weber's Test: |
Place the tuning fork in the centre of the patient's forehead and ask if it is louder on one side or the other.
Normal => equal loudness on both sides |
Rinne's Test: |
Place tuning fork on the patient's mastoid process with the prongs perpendicular to the ear, patient shoud identify when they can no longer hear it. Then move the tuning fork in front of their ear.
Repeat for both ears |
Rinne's Test:
Air conduction > bone conduction = Positive Rinne's
Bone conduction > air conduction = Negative Rinne's
Weber's Test:
Heard in the midline = Normal
Louder in a ear with a negative Rinne's test = Conductive hearing loss
Louder in a ear with a positive Rinne's test = Sensorineural hearing loss
CN 9, 10, 12 Glossopharyngeal, Vagus, Hypoglossal
CN 10 Vagus |
Ask patient to perform a loud cough. |
Articulation |
Ask patient to say the days of the week. |
Depress tongue with tongue depressor |
When patient says "ahh", the soft palate should elevate symmetrically.
Will deviate towards the stronger side if palsy. |
Gag Reflex |
Not normally tested in a conscious patient
Sensory - CN9 Glossopharyngeal
Motor - CN10 Vagus |
CN 12 Hypoglossal |
Ask patient to open mouth, stick out tongue, move tongue from side to side, examiner places hand on patient's cheek and asks patient to press tongue against his hand |
CN 11 Accessory
Patient shrugs shoulders |
Ask the patient to shrug their shoulders using your hands on their shoulders to resist the movement.
Symmetrical |
Sternomastoid |
Ask the patient to turn their head to each side using your hand on their cheek to resist the movement. |
Completing the examination
Thank Patient
Sanitise hands and equipment
Other examinations to consider:
• Neurological examination of the limbs
• Mental state examination |
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