Cranial nerve examination

WIPER and General examination

In an examination the mnemonic WIPER may serve as a reminder to wash your hands, introduce yourself, gain permission, expose the patient and reposition them as appropriate for the examination about to be performed. Simultaenously you should carry out a general examination noting the patients appearance, condition, and any clues from the environment. This forms the beginning of your mental account of the patient and can be remembered as ACC. See General Examination and Observations for more detail. The standard format that follows is always inspection, palpation, percussion, auscultation, and contemplation (Osler, Canadian turn of 19C physician, father of modern medicine). Additionally it is helpful to carry out the examination routine in a set sequence for example general, hands, neck, face, then specific, in this case, the chest wall. Finish by carrying out, or listing, relevent further clinical examinations and investigations, and presenting your findings. N.B. It’s a good idea to aim to be able to define, explain, and suggest a differential for any finding that you report.

Cranial Nerve examination

General inspection

  • Is there a facial palsy?

  • Is there abnormal posturing? (you should spot an hemipariesis)

  • Does patient seem confused? (you would also like to establish the AMTS and test higher mental function - 7 domains

    1. Consciousness i.e GCS

    2. Orientation to person, place and time

    3. Attention and Concentration (subcortical function) (digit span test, serial 7’s, WORLD)

    4. Language and Speech (frontotemporal lobe, cerebellum, musculature) (Dysphasia/Dysarthria)

    5. Memory (temporal/parietal lobes) (antereograde/reterograde, implicit/expicit, verbal/non-verbal)

    6. Visuospatial skills (non-dominant hemisphere) (geographical orientation, constructional dyspraxia, dressing dyspraxia)

    7. Executive functioning (frontal lobe) (proverb interpretation, verbal fluency, cognitive estimates, Luria’s FEP - fist, edge, palm, utilisation behaviour, appropriate behaviour)

  • Is there an NG tube?

  • Are there any disability aids at the bedside?

Cranial Nerves

  • I ’any change in your sense of taste or smell’

  • II visual acuity with snellen chart (with glasses, without and with pin hole) ishihara plates visual fields testing inc bilateral challenge fundoscopy reflexes, accomodation and direct and consensual pupillary reflexes (PERRLA D+C, pupils equal, round, and reactive to light, both direct and consesual response, and accomodation)

  • III, IV, VI ’follow my finger’ tell me if it goes blury or you see double at any point’

  • V sensory, opthalmic, maxillary, mandibular, ’can you feel me touching’ ’does it feel the same on both sides?’ motor, ’clench your jaw’ feel masseutus and temporalis reflexes, jaw jerk and corneal reflex

  • VII ’Raise your eye brows’ ’Screw up your eyes’ ’Blow out your cheeks’ ’Big smile, show me your teeth’

  • VIII ’I’m going to whisper a number into your ear, please repeat the number’ (distract by rubbing fingers) Rinne’s and Weber’s tests

  • IX, X gag reflex and swallowing open mouth and say ’arrh’ (look at uvula – shd see rise centrally)

  • XI ’shrug your shoulders against my hands’ ’try and turn your head against my hand’

  • XII ’stick your tounge out. And move it side to side’ (inspect tounge for wasting and fasiculation)

Completion

Either do these things and/or say ”To complete my examination I would....``

Further examinations

Higher mental function testing, Peripheral nervous system testing, Cardiovascular examination (e.g for carotid bruit, AF in stroke patient)

Further investigations

  • Simple tests: urine dipstix

  • Blood tests: Fbc, U&E’s, inflammatory markers, glucose, lipids, clotting

  • Imaging: ECG, CXR, CT Head, MRI

  • Special test: echocardiogram, doppler USS carotids

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