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Okay, so So just a quick summary of everything we've gone through since I just started recording the lecture. So the first part of the examination is the inspection. So you want to look for the medical power of attorney earlier? The walking frame hearing aids and glasses on. Then you want to also look for any medications. So, any new or toxic or auto toxic meaning toxic to the you can now, um, medications. That's going to be for a samide aminoglycoside and aspirin. Um, aspirin. You want to also ask them what they were started on the aspirin for? Because it was if it was a previous stroke, then, um, the predisposes them to be more likely to be going through a stroke right now. If they're presenting with some type of neurological pathology on, then the last thing you want local like I just mentioned is pathological signs. So that's thinks like muscle wasting facial asymmetry and fasciculation. Now, facial asymmetry specifically is a really important one to be aware of, because, you know, I only want to localize toe what side of the face. But you also want a localized to what half of the face so if it's left right side on, but if it's bottom or top half, So both are equally as important to take into account when looking at the pathological signs in the inspection stage of the examination. Does that make sense of all? Um, if if anyone wants me to repeat something, I will repeat it. But hopefully that will make sense so far. Yeah. Does that make sense of us? Yeah. Okay. Thank you. Um, all right, so now we're going to go to the nose and mouth. So, like, so, um, I like to go through the, um, carnitine of examination in terms of the region's of the face. Just because it makes the most sense for me, Some people would prefer going through the order of the cranial nerves. Um, I just feel if you go through the regions of the face, then you're not revisiting the same regions of the face, and it's just more comfortable for the patient. Like, if you're looking at their nose, you might as well go through all the examinations. You need to go for the mouth, especially in covert times when, um, like everyone's wearing mosques. So you need to ask the patient to remove their mask and to do a lot these examinations. I'd rather ask the patient to remove them. Ask once on dual the examination. So that's the only reason why I'm going through this way. Um, so first thing is smell now smell is a very, very, um, we'd want to test in the sense that there is no, like, direct sign. You can see everything is completely reported by the patient. So, for example, first thing you would ask them is if they've noticed any changes in the sense of smell. Um, Andi, this convenient birth way. So if there's a sense of smell, has either heightened or if it's damp and both you want to be aware of. Everyone remembers like if they have a loss of sense of smell but no loss, people often forget that having ah heightened sense of smell is just a simple tint to know when it comes to do in your neurological exam, then the next thing, if they do have a reduction or a heightened sense of smell or any change to that sense of smell, you want to test that with some type of distinctive smell, using either fragrance world on cotton wool. So really common one is like tea tree oil on cotton Will Another really common one that you often Seymour on any or like more in the hospital setting is, um they will usually be some cup of coffee somewhere. So the smell of coffee is a really common one to testis. Well, something just distinctive. That's the main thing when it comes to assessing the smell, um, for the nose in the mouth for for the cranial nerve one. So now, moving on quite fall down Teo Creatinine of nine. So that's gonna be your gag reflex on swallowing now when it comes to the gag reflex. Um, so this is for the CP examination for Imperial you to students. But, um, when it comes to gag reflex in the CPI, you're not going to be asked. But in really practice, when you do the gag reflex, you often don't really do it that much in real practice either. But when you do it, you want to know only assess whether the gag reflex is present. You want to assess whether it's present on both sides off the, um palate and you also want to assess whether it's equal on both sides of the palate. So what that means is, in terms of how easily you can see the gag reflex, can you see the same level off a reflex on both sides? So that's really important to take into account and then swallowing. The easiest way to do that is just ask the patient to drink some water on, swallowed the water and just see the water pass through and see if their throat if there's any issues with swallowing. Um, now some people might say, Oh, you're just assessing liquids at that point in time, Um, what about solids? I think when it comes to the initial neurological exam, the swallowing part, you just want to make sure that the actual nerve is intact on on. But water is more than sufficient for that point. If you're going down the root off things like accolade a on do some type of structural deformity or structural difficulty in the esophagus later on, then you can assess things were using like a barium swallow if you're not worried about swallowing solid specifically, but in this instance, we just want the simple um candy swallow or can they know on water is more than sufficient for that now, Going to the uvula. So the uvula, um, is for cranial of 10 on the important part for this, um, is so you ask the patient to say on this is the main reason why I'm going through nose and mouth first, right? Because you just want to do all the examinations you can do with the patient's mosque off first so that they don't need to keep on removing their mask in covert times. Um, so when you assess the uvula, you ask the patients say are on. Then you check. Um Sinemet for symmetrical. Rise off the uvula on the important part here is if there is a lesion, the uvula will deviate away from the side of the lesion. Okay, that's an important note to make here specifically for the cranial nerve. 10. So if the uvula it deviates to the left, you have a region. You have a lesion on the right cranial. 10th cranial up on def. On vice. A versa for the right now, finally moving to the tongue so the tongue is going to be for cranial enough 12 on and you just ask the patient to stick their tongue out on in terms off What you wanna assess forces that again? Is there any deviation to one side of the other on the tongue? Unlike the uvula, it will deviate to decided the lesion. So if it's on, if the tongue deviates to the left lesion is on the left. Um, Colonel, enough 12 if it's to the right price of Asa. Um, so this is actually quite ah important one, I guess because, um just from my experience, when I did a placement in any one of the any consultants that they actually found, um, the reason for a stroke in a 19 year old child, 19 year old kid, because off just assessing tongue deviation. So it's one that a lot of people might forget because they think it's a really simple one. But you want as complete off a neurological examination. Cranial nerve examination is possible. So never, ever forget it on document what side? The deviation is, too, because you you need to know what side there's deviation to, because if it's the uvula, you have deviation away from the site of the lesion. If it's the tongue is towards the site of the lesion. Great. Okay, so I'm gonna move on. Um, if there's any point in time, please feel free to just on you and asked me a question if I'm going to fast also, please, just tell me. Um so now moving on to the eyes. So the eyes you on a a test of is in on vision is primarily with the criminal up to now, The acronym that I used when it comes to remembering vision is Africa so Afro standing for acuity, fields, reflexes on optic disc. So acuity you want to assess using either a smell in shot letter or magazine on also issue horror plates. So the snail in shot is first of all, just the chart. I'm sure you remember like if you go to a knob Titian's you'll see the chart with the big letters of the top and then decreasing, decreasing in size as you go down to the bottom. So that's the main visual acuity tester. And that's what they mean when you see things like 2020 vision. That's what they're basing off off for writing that in medical note Now the letter of the magazine is just so that you can assess if a patient is your long cited on, then issue horror plates. Are those circles with made out of colored dots? Um, and then there's a number usually inside made out of a different color. And that's just to assess color blindness. Um, now, then moving on to fields. So fields is for visual inattention. Now, visual inattention is basically you. Ask the patient. Teo, have one eye closed, so they use the palm off their hand and just gently closed. I you don't want them to press on the eye, so that's an important point. Make. You don't want them to press their palm on the eye because literally in, like, two seconds, you're gonna ask them to do the exact same test on the other eye. Are, which was just closed. So that's why just gently rest their palm on the eye just to close it on. Then you have both your hands out like this, and you move one off the hands and you ask the patient, um, would 2.2, which hand they use just moved on that that's pretty much it when it comes to visual inattention. When it comes, the visual fields, the exact same thing You start off with closing one eye with one palm on. Do you move the hand in words when you ask, the patient went out which hand they just saw move in. You just ask them to point out which hand they saw in words. Um, on the bland spots again, you do the exact same test, but you just use the red neurotypical when it comes to a blind spot just because that red color is really important for the blind spots. Um, a n'importe No point to make here is when you excess for feet fields. You want to be sitting at my level with the patient on. Also, you want to be comparing their visual fields to you're on visual fields, assuming that you have no deficits in your visual fields, if you do have any deficit in your visual fields than the best way to go about, this test is possibly. Just ask a colleague to do this section off the test because the main reason is when you went, you want to compare their I do your your your eye eyes on the same side. Right? So if you have a visual deficit or or visual fields deficit in the first place, it doesn't really make sense to do that test. Okay, um because you you're not really going to get an accurate reading, like even if they have, if they have a visual field deficit less than, um, yours. If you do have visual fields deficit, then there's then this test is and really relevant. So that's why you want to just get a colleague to do it for you. Um, then you want to also assess reflexes. So the way you assess reflexes, you want to assess accommodation. So the way you're set, that is again you ask the patient, just sitting straight, you ask the patient to focus on a point, um, in the back, or like in a in a wall, just behind you on. Then you ask the patient to focus on your nose. Um, so and then you just see if there's any signs of a nystagmus or any signs of difficulty and actually doing that, and then the final part reflexes is the pen light tester you want to check for consensual on direct people. A really reflects. So direct is in the same in the same people that you're shining light into. You want to see if the pupil constrict so doesn't on, then consensual? You want to check the other people on that you're not shining light into, and then you also want to do these swinging light test so they're swinging, liked us, just moving from one side to the other. Um, and you want to basically see if there's any changes in the ability for the ah, the pupil to accommodate for that like on then Finally, the optic disc is assessed using the ophthalmoscope. So the optimal scope, um, in my experience and hospital isn't really used in anywhere, apart from the ent, you do see it now and then in any but, um, it might have just been the any I was on placement that, but not one of the ophthalmoscope was actually working. Um, so take it, like with a pinch of salt when it comes to how much you might be asked in the CPI exams. But it is an important skill to understand, and the main thing you want to assess for is you're on a visualized the optic disc, and you want to see if there's any swelling or papilledema and the optic disc. Um, and I have a separate slide just going through a colonoscopy after this. But just just remember that in the back you had the main thing you're looking for. Is any signs of optic disc swelling? Okay on, then. The next thing you want to assess in the eyes is movement. Now, movement is a much easier, um, test to do so. It's pretty much just assessing in terms of inspection. You want to see if there's any signs off? Um, partial Tosis. So all that means is partial. I lied closing in things like corner syndrome or complete Tosis in a cranial nerve in a third cranial nerve lesion, for example. Um, And then, in order to actually assess the movement, you want to do the hate test. So that age test, all that means is you're making a page with your fingers, sir, you want to basically assess the ability for the eye to go to a lot of different places? Um, I'm sure most of you know what the Hey justice. I'm not gonna go through the whole test. But just to summarize, basically all the hate stress is means is you want to start off centrally on. You basically just want to make it eight with your finger. So you want to go like this? You wanna go like this? You want to go down, You want to come back centrally, and then you want to do the same on the other side on. You just want to assess for any signs of nystagmus or any signs of difficulty and actually doing that. I'm movement on the really easy way to remember. Um the the colonel nerves that innovate the specific muscles is L4 and s are six. So hello. Hello. For meaning? Lateral oblique. Um, that is going to be innovated by your fourth grade. Enough and s are six. So, superior rectus that's going to be innovated by your sixth cranial. Enough. Now go through the, um and asked me off the specific muscles, But just keep that in the back. You mind off L0 for us are six. Um, for the ah colonel nerves that innovate thespian. If it muscles and then finally also want to check for saccades just saccades is the easiest way to actually assess. It is probably just asking the patient read through something, and then you can see if there's any saccades. Um, president, That's the easiest way to assess sophisticates. Okay. Excuse me. Can you repeat them? What muscle does the sixth nerve innervates? Yeah. Yeah. So the cranial nerve six innovates the superior rectus. So I do have a diagram later on. I'm going through each of the muscles on going through each of their movements. I just want to make sure is not the little rectus. Ah, no, not to my knowledge. It's superior. Rectus is from my knowledge. Um, I can I can check that for you after this, but I remember as L0 for s or six. Um, So I Yeah, that that's what I remember as, um, I could be wrong. I will confirm that, Um and then just Yeah, if there if there is a correction, I will. I'll send anemia toe everyone who's attended just just a corrector, or I'll correct it in the slides on the summary guide, but, um, eso for Ela is it s o for okay. I might have got it in the health and the s is mixed up. Sorry. I think you're right. That may So it is s o for last six. So s O for, um, superior oblique for a natural rector. Six. Um, I'm sorry. I might have just model them up when I was making these lights. Um, thank you for pointing that out for me. Um, so superior oblique for on larger Erector six. Thank you for loving. Um, okay, so we'll move on to the face. Um, now is everything else in the ice makes sense? Yep. Yeah. Thank you for that. Um okay, so sensation in the face. So you want to assess for sensation? I'm using just a piece of cotton wool. Um, now that you can assess for sensation using other mediums. But just for this e p a, um, for the year two students. Ah, that's imperial. The main way is caution. Well, at this stage. So the way we want to first war assess for sensation is you want to ask the patient, close your eyes. You want some type off reference point before you start testing for sensation in the face. So the common place for that is just the collar bone. So just tell the patient that you're going to touch their collar bone, and this is what it's going to feel like on their face on. Just ask them to say yes when they feel it on the face. Um, it's important to just gain consent before you do that, because the collarbone is a bit of a sensitive area. Okay, so the areas you want to assess is the ophthalmic, the maxillary and the mandibular. So if you effectively just split the face into thirds, Um and that's gonna basically tell you for the V one V two and the three for the, um fifth Cranial enough, um, for sensation. Um, that's pretty much it when it comes to the sensation. Now, when it comes to the month, uh, cells for the fifth cranial nerve, you want to ask the patient to basically clench their drawers and you want to assess for the temporalis muscle. So up here on also the master muscle. So you want to ask for both of them When, um when they claim to their jaw, you want to assess for both of them, so you need to ask them to plan to their drawer twice, or if you can do it in one. Go do. And one girl. Um because then the patient doesn't need to cleanse the drill twice, and it's just easier on them. But just be aware you need to assess for the temporalis muscle as well as the massacre. Okay, um, then facial expressions. So facial expressions is to assess for the seventh cranial enough, Um, on the seventh grade, you enough. When it comes to facial expressions, I would say the most difficult part of it is actually just the phrasing. So what I would do is try and use a simple off language is possible. Like I know some places out there Will will ask you to ask the patient to make a grimace on. You'll be surprised. A lot of patients don't know what grimaces, so the easiest way is just awesome. Patient. Could you raise your eyebrows? Could you scrunch your eyes? And when that's crunching their eyes, you want to also just gently pull like this just so that you can assess if the muscles can actually go on, um, against resistance. Um, you want to ask them to show their teeth. Um, the reason. Being sure that teeth is like, Okay, a lot of people will know what smile means, but just sure that teeth is like it's just simple language. Um, and you'd be surprised, like especially in any loss of people. Just wouldn't be thinking like straight because they'll just be in a very anxious situation. Um, so show your teeth is just a very simple instruction, um, and smile as well. It's a bit weird being in that anxious situation on the niacin patient to smile because, like they're stressed as is. So if you ask them to smile, which is supposed to be something to show happiness, it's a bit just weird for the patient. So that's why I suggest you rather stay. Just show your teeth and then pass your lips so really easy another way. So pass your lips is effectively for the grimace. But even if pass your lips doesn't make sense for them, the easiest way to do it is just so uncovered Times. Obviously, since you have a mask on, just move your mouth down and then just mimic out the action to the patient. Um, you've probably heard this a lot when it comes to doing upper on lower limbs. Um, last week, Um, but the the easiest way to ask a patient to do anything, it's just moving out to them if you can't find the words for it. So past your lips is probably the one which a lot of people find difficult to Austin patient to do. Um, because a lot of people don't know, Like so again in that anxious environment and everything are patients just might not understand what you mean. So and then the final thing, you ask the patient part out their cheeks, and when they puff out their cheeks, you also want to provide a resistance, because again, you want to check whether the muscles can work against resistance. Okay, great. All right. So now I'm just going to move on everything full face make sense so far for everyone. Yeah. Yeah. Okay. Just, uh, great. Thank you. So is and get I know I I know this part is a bit didactic, but, um, one of the structure of the exam is just one of those things that is very dead. Actiq, Um, I do have some questions towards the end and we'll revisit the case and we'll have a bigger discussion then. But just bear with me while we go through that they're diabetic part. So there is in the gate. So we want to assess hearing. Um, now, the first thing when it comes to hearing is like smell You want a first to Alaska patient? Have they noticed any changes to their hearing and again, like smell you want? Ask how they noticed any dampening or heighten sense of hearing because both are equally as important. And when it comes to, um, the hearing doing him to know how to do all of the different visual test? Um, I think we only purchased it. So in terms of so question in the chart is just do we need to know all the different test for the, um, vision? I don't say, Um, there aren't that many tests. To be honest with you, I think for the CP, I think they might have removed cranial nerves just for this year again because of the whole Kobe situation. So I don't know if they actually gonna assess it or not, but because since the covered situations improving That's why we're doing this session, because we don't know if they're going to do it or not. But I would say, um, learn all of them because even if you don't need to know for a second your exams, you definitely need to know for 30 or exam so that early you do it the better on if you just use the acronym Afro. So for, um, acuity feels reflexes on optical disc. That's the easiest way to understand it. So it's just Afro. And then there's three things you want to assess for each of them. So for the acuity you on assess for, you wanna say Snowden shot. You want to assess the letters in the magazines on you want to assess, issue our plates. Just learn it that way. We'll have, like, a systematic approach, because I do understand where you're coming from. The, um, the the the Eyes is probably the hardest part off the whole of cranial nerves just because the sheer fact that there are so many tests for it, But once you get past the eyes, everything else is very, very easy. So just memorize. I guess the acronym, Um, I tried to summarize as best as I could in the summary guide, which we will push later. Um, so just go through my the summer grade that I created on I will change the summer guide. Teo have also the correction to the S 04 elastics. I think I just got my ass is and else mixed up there, so just Yeah, that's the easiest way to go through that. Um, does that answer your question? I'm going to take that as a yes. Okay. Great. Um, cool. So going back to hearing so hearing when it comes to is in the gate. You want to ask the patient like I said, but there's also want to come to the hearing. There are two different ways of assessing it. So you can crudely test it. All that means is in general is the hearing working on. There are some specific tests as well. So when it comes to crude testing, you basically just want to close their here. So don't actually put your finger in there because, obviously, like infection risks. And it's just uncomfortable. Just use something called a trigger pull. So all that means is you use the triggers off the ear anatomy on you just pulled the trigger triggers over the, um, over the there. It just to close it so that when you whisper on one side just a number, you ask them, you whisper a number and you just ask them, What number did you whisper? Um, and then you do on the other side. Obviously, in any environment, this is literally impossible. Um, so that's when the specific tests come in so handy. So the specific test is using a tuning fork. So the tuning fork, Um, so the tuning fork is, um, a 5 12 tuning fork. Now, to be honest with you, I have used a 1 28 and there's been no difficulty. So it doesn't really matter like what frequency you're using unless you're like carrying out specifically, just like off the logical exams. But in in the in the mark scheme for the CPA, it says, 5 12 tuning fork. Um, that's usually the most common type of tuning forks. That's why I just mentioned it on. You have to carry out something cold. Renee's on Webster test. Now you've got probably might have heard this, but I'll just go through it. So all you want to do is basically strike the tuning fork, and then you want to place it either to the mastoid process of just behind the air, the burn just on both sides on also, you wanna, um, place on the forehead? Um so, really, knees is the master process, and then Webber's is the forehead. Um, Now you just want to ask them, Can they hear it? Is there any change in the hearing on the main reason why you do this test is just to assess for conductive on sensor sense. You in your old hearing loss. So conductive is to do with the master process and censor in your eyes to do with the forehead primarily, Um, but since you on your oh is also with the crude, um, crude hearing that you do, But obviously you can do that very easily in a GP setting because everything's nice and calm for then in a in the setting, when there's 15 billion bleeps everywhere, you're not going to hear anything, even for you. It's going to be difficult to hear your own whisper, let alone the patient. So that's just a caveat. When it comes to the crude hearing test on, then the next test you want to do is balance. So violence again is the eighth grade Enough on again. You start by asking, Have you noticed any changes to your balance? A new Ask the patient to walk on the spot. You ask the patient to walk in a straight line and then you ask the patient, Um, could you do a test on them? Who? The Dix Hallpike test now the Dex whole pipe test. Is there a specific test for something called benign paroxysmal positional Vertigo, Um, or BPPV. So you mainly use the base All all you're assessing is for things like nystagmus when moving the head in specific directions. So the dix Hallpike test, um is you You you may need to use it for BPPV was just a diagnostic test for that. Or if the patient tells you that they find that their violence girls, when they move really quickly, it's another time you do. Do the dix Hallpike on all the the the Dix Hallpike is is you basically ask the patient to tilt the head to one side and you ask them to move slowly backwards on on the examination bed, and then you can see a nystagmus. I'm quite clearly like you. If you are ever in the hospital placement or in any placement, specifically, try and just ask around and see if there's, like, a BPPV, um, patient because of loss of people Come in. Or just ask if there's like a dizziness patient. Because dizziness is also a really common time. You Did you do this, Dix Hallpike test. Um, on. Do you concede the nystagmus? Quite clearly. If they do have BPPV or any type of positional vertigo. Great. Does that will make sense for is and day. I'm going to take that. Yes. Um, Yep. All right. Great. So I'm going to move onto shoulders and neck now, So shoulders the neck, um, is primarily old. Yeah. Yeah. Go for it. But do not do the one where they put their hands and they just walk or the left upper leg, and then just walk. That is no, that no part of gait is Well, um, which, uh So So you would ask them to walk on the spot and you'd ask them to walk in a straight line, and you'd want to assess the gate that way. Um, I'm I think that I don't know about the hands back in front of them didn't eat a dealer. I'm not aware of that. No, I think that might be a very I think that might be a very specific just gait assessment rather than to do with all of the cranial nerves. So that might be one like specialist test that you might just do just to assess gate. Because, like, for example, if you're worried about any type of server Bella disorder, that might be a test, which you do, um, specifically for things like cerebella disorders, but not part of the creator. Like, not part of a generalized cranial nerve examination. It doesn't make sense. Does great. Okay. Um, any other questions? Okay, great. So going back to the shoulders and the neck. So the shoulders and the neck, Um, this part of the exam is pretty much all just to do with assessing muscle on musculature. So the standard cleidomastoideus basically have your face. Ah, you have your hand on ah towards one side of the face and you ask them to basically ton their neck, Um, pushing against that high and you provide a little bit of resistance and you want to basically just assessed for the sternocleidomastoid on. Then you do the same on the other side. And this is for the sternocleidomastoid on. Then finally the trapezius. You just ask them to shrug your shoulders and you provide a little bit of resistance, and that's for your cranial nerve. 11. Great. Okay, so that's all off. The different part of the examination now just going a little bit more in depth for some specific parts. So vision, like I mentioned. So this's just a summary. Want one that you asked up how all the different visual test. So these are primarily the visual test that you would most likely be assessed on in the c p A. A, um, a visual acuity, color feel, color, vision's visual fields and blind spots. He's the main visual fields, but the main reason why I want to destroy you guys. His attention to this slide is the fundoscopy. So the fundoscopy is to do the optic disc, the macula and fovea and the retinal veins arteries. So I have a picture of it here so this to get to the stage where you can actually see this using a fund, a scope takes quite a while, um so even, like, quite advanced, even even quite later down medical students and also a lot of doctors find it's still difficult to use. The fundoscopic is one of those things where if you don't do it day in, day out, you sort of lose the touch of it. Um, probably the best people to learn for Nonschool P Front or practice for endoscopy is in IBD GP setting because it's the one place where all the fundoscopic surprisingly work or in ent in hospital. Because you nose and eyes are not ent on my saying, um, ophthalmology, Um, Gasol's that's that's the main place where you would do for endoscopy. So in terms of actually assessing the um, Fundoscopic ah ha ah, you want to find the optical disk okay. And then from the optical disc, you can find everything else to the retinal vein. The Retin artery on, as you can see, like the rest of the artery, is a lot more wiry and a lot more branched, whereas the wrap it in a vein is quite thick and quite straight. Not that many branches. That's the predominant difference between the retinal artery in the rational vein and then the macular and the phobia. Um, so the the macula is the area that encloses doctoral fovea. So the phobia is that dark, just red spot over there, Um, on. But the main thing you want to assess is the optic disc, because you want to assess for things like popular Dema um, popular demand. Meaning disc swelling. Um, because that's a sign of raised intracranial pressure on that. Something you want to take very seriously and treat as soon as possible. Just don't make sense for everyone. I Yeah. Oh, no. Any questions? It's fine. Yeah, Great. Um, thank you. So just going through the eye and ask me So, um, so just going through all the different muscles. So there are four muscles around, um, the left right top and bottom. And then you also have these two muscles attaching obliquely. So the superior rectus, like the name, suggests it's superior, um, to the eyeball on it, at the very top. And it moves eyeball upwards. The inferior rectus inferior. So? So the bottom of the eyeball move downwards. Medial rectus is medial to the nurse, so it's it's medial to the body. So it's towards the nurse. So I moved to I inwards towards the nose and then the lateral rectus is lateral to the body. So it's towards the outside this towards it moves the eye towards a um and then you also have the superior oblique and inferior oblique. Now, oblique just means that it touches at angle. Um, so that's why superior ble attach is superior iliac at an angle to the eyeball and invariably attach is in fairly at an angle on like the, um, diagram is trying to suggest all the inferoapical in there superbly instead of just going up, down left, right. You can also move your eyes out this way and you can move your eyes out this way. Um, their main muscles that allow you to that is the superior erect, superior oblique on the inferior oblique on. But I just have a summary off all the different, um, functions of each of the muscles over here. But I think the easier way to understand it is actually using the diagram. I just have both here because I know some people are more image orientated and some people are more text orientated. I just want the slide to be easy for both types of learners. Um, does anyone have any questions regarding the anatomy of the eye or regarding the function's off the different muscles and any questions? I'm going to take that And, uh um, so they just just just for their CPA Um, just a Nexium focus. This is the type of question they usually asking DeVivo just after you do your examination. So they'll have, like, an anatomical model of the eye on. They'll ask you to, um their they'll point out or muscle and ask you what muscle is this? Um, that's a very light, common Bible question for the cranial nerves. But again, you know nerves. They might have it in the CPA. They may know it really just depends on how the corporate situation is gonna play out. Um, fine. So correct needle for Romina. Now, the coronal foramina is a very, very long list just to remember. But if you think about it is sort of a ranged in a logical order in the sense that the the higher. The 1st, 2nd and 3rd, like cranial nerves are more towards the front off the chronic basis. Whereas the higher numbers, like the 10 11, 12 are more towards the, um, back off the colonel base. So I have this list off going through all of the different gray. No nerves are being the first, the cribriform and the optic optic. Okay, now and everything. Um, but this is how my mind works. So I always prefer, um, during the reason being is, you can, um, combined a lot of information into one picture. Um, so I would say so. This picture I believe I got from, um, teach me and asked me. So this picture is really, really good. Has summarizing all the different, um, cranial nerves on, uh um exits, um, in terms of their cranial foramina. So the cribriform plate being for the cranial nerve Juan Optical canal being for the credit enough to, um and so on and so forth in terms of a couple of tricks here and there for memorizing, like how to work out. Which kind of nervous which? Oh. Oh, a really easy. A really easy acronym to remember. Is Ross so rotunda. Um Oh. Volley on. Spinoza. Um, once you understand you're in this region and you can usually work up the cribriform plate because it's towards the front and there's a lot of different holes in there. So once you workout Ross on the cribriform play, you can work out these two because the superior orbital fisher, if you think about it that there's like a line over here cost by the, um, the sphenoid bone on a fissure is Maurie like a slit rather than a canal, which is like a, um, like a like a circle. Right, So that's how you can work out like this is your superior orbital fisher on Be right next to your orbital Fisher. Think I is your optic canal? None. If we move further down, there's, ah, couple more, which are a bit more difficult to remember again. If you think about the that the the So you have the form and Magnum over here, Um, you can quite clearly see the front and Magnum. The Hypoglossal Canal is just next to the for a Magnum, because if you think about it, hypo so two means like below. So like it's just below the foramen Magnum. I know it's a really silly way of remembering it, but for before that Carina Foramina there is no easy way to remember is literally Everyone needs to find their own way of remembering it. I'm just illustrating some ways on some like tricks here and there that I've picked up in terms of remembering it on then the jugular foramen. The way I remember this is the regular foramen is because of the fact that is right next to Hypoglossal Canal. But okay, how do I tell the jugular firm and apart from the internal accused of Meatus on the way I remember is, if you look at the jugular, foramen is a bit quite a bit bigger than the internal Christian mediators on. It makes sense because that's three kernel. Now it's coming out of the jungle firm, and but there's only two coming out with the internal acoustic mazes. So it makes sense. The bigger one, which has three colonels coming out to that would be the jugular Framan, and then the smaller one is the internal interesting meter. So in actuality, you only really need to remember like 1234 five off them and then the others. You can work out from those five. So I know I know that really, really just silly and weird ways to remember. But if you can minimize the amount you need to memorize and then just work out the rest, it's just less information you need. Teo, take into your brand and you have more space for other things. Right? So that's the only reason why I just gone through those, like ways of remembering it. If there's any question so far, just just please feel free to toe on you and ask, um, like, because obviously you can only be ask so many questions if I the chat, um, so just just just please feel free to call me and ask. But it is everything clear so far for everyone. Yeah. Great. Thank you. Right. So going back to Mrs X. So, Mrs X, um, if we go back to the all righty, if we just go back to what misses except like, all right, So I'm guessing a lot of you just by the look of the patient worked out like, what's going on and what's going wrong. Um, but Could everyone just tell me what actually is going on? Just in terms of look, not not the actual disease or the the pathology, But what can you see is actually are abnormal in this patient. Um, please, for Frito on you or just put in the chart. What? What's actually abnormal official, per is is Yeah, great. Okay, You want to go a bit more? Describe? It's a bit more on the left, actually. Yeah. Okay. Do you wanna go a little bit more than that? And ah, we can see that the below half of the face and the upper half of the face is affected. Great. That's what I was looking for. So you can see that it's the left side of the face, and it's the whole side of the face is all right? Yeah. Yes, uh, from that you know that something's gone wrong in terms off the seventh cranial nerve. Yeah, because your seventh cranial nerve is primarily the one which actually supplies all of the facial muscles and allows you to produce any type of facial expressions. Doesn't make sense. Yes. Yeah. Great. Okay. Um but yeah, So that's that. So really good description. Actually, they're well done. So, um, the main thing when it comes to describing any tighter in the charges or those facial drop. So, yeah, um, you can describe it really, really simply like facial drop. Or you can be very descriptive after saying it's a facial paralysis on the left side of the face on this on top and bottom half the face. I would say whenever you describe any type off sign so Sinus, where you can see symptoms of, uh, the patient tells you, right, eso any type of sign whenever you describe it the morp precisely. Do you describe it? The easier your job becomes. Okay. And the easier the job off everyone else in your team becomes because it just means that you can get to your differential diagnosis and your definitive diagnosis so much more easily because off the fact that you've taken the time to properly describe your sign. Okay, so going back to the slide off Mrs X is Ah, Miss exes. Um, presentation. So the main reason why I asked you so much good. You go a bit more about that. Could you go? But more about that is because As you said, it's on the top on the bottom half of the face on. What that tells you, right is that it is a lower myrtle, Asian murder in urination. And the reason why it's lower murder neuron lesion is because if you look at this diagram, right, you can see that the upper motor neuron. Okay, there is innovation from the upper when it comes to both sides of the cerebral cortex innovating birth off the nuclei for the facial enough, right? You guys can see that. Yeah. So if there is a lesion in the upper motor neuron on one side, the other side of the upper motor neuron right will innovate to a degree, specifically the upper part off the face tense. Why, in an upper motor neuron lesion, you only see deficit unfaithful paralysis and facial drop in the lower court. Trim off the face. Okay, But in a lower motor neuron lesion, you see it both in the lower quadrant on the upper quarter, off the affected, um region. Okay, because of the fact that it's I, it's after the nuclear. So it's after all of the nerves are basically become one. And because of the facial nerve. And once it's become the facial nerve, even though that's three branches, all of it's coming from that same nuclear. So if there is a lesion in the nucleus or there's a lesion underneath the nucleus effects all off the different muscles, supplying that side of the face doesn't make sense for everyone. Yeah, on uh, it's just a question, isn't it? So, uh, it would be it would be on the opposite side. So the reason I'm sorry. Opposite side if it is on the upper motor neuron. Because if you think about it, if it's going from the upper motor neuron. Right. Um, okay, someone doesn't understand the diagram, so we'll go through the diagram again. If you look at the diagram, right, you have to serve the cerebral cortex. Okay on. Then you have the upper motor neuron just on to your question really quickly for the upper motor neuron. Um, it will be paralysis on the opposite side because of the fact that the affected side, the opposite side of it, will still provide innovation. So therefore, that side will still get upper face innovation from the little bit in this instance right. Let's say the left is affected. The right still goes through. So therefore the right still provide is getting innovation from the right upper. But there is no left left, left upper innovating The right lower doesn't make sense. So if we have a stroke Yeah, the upper motor neuron is damaged. Yeah, and we have Ah, the left diagram affected. I'm I mean, there is a is affected the lower quadrant. Yes. Yes. All right. So if the seven is effective Yeah, carry on. We have ah, half of the face effective. Exactly. I know it's paradoxical to the way of the the way you'd think you'd think, Oh, if something happened up a moot in you're on, that it would affect your whole face. But the thing the reason being right is because two thirds of the innovation for the nucleus comes from the opposite side. And one third comes from the same side. So if it happens in the upper motor neuron two thirds off, that innovation to the nucleus isn't coming. But one third is still coming. So therefore the upper half still can function. But if the lower motor neuron is affected, then it's on that same side because it's already crossed and discuss stated to the opposite side. So therefore, it's following that same line from the nucleus directly to hear. Does that make sense on, uh, would ever like me to go through this diagram again? Can usually. Yeah, it's the Okay, let's just called the pink and black. Yeah, if the black lines. Uh huh. Isn't it? And that would still, um, mainly right. We repeat that. Sorry. Okay. For example, you feed you if you look at the one with, um and yeah, I see that if if you caught the 123 from the inside, we relieve someone that screen straight down the pink, then, uh, left side of the face, the other side. Well, not stimulate. If we cut all of these, just the three. The first three. Just the foot. Okay, so, um, if you caught just the first three, you have very weird presentation that, um you'd be very low. Actually, you'd be very lucky for that to happen. Um, but it's like, basically right. Only one of them's going directly straight to the nucleus. The other three are crossing over. You can see that right? Yeah. Yeah. So it's like, if you have this off a motor neuron lesion happening over here. Okay. Right. These three are crossing over from this side on to here. Only this one is actually not coming. Right, Because only this one is not coming to this side. But on this side, these three are not coming, but this one's still fine. Does that make sense? Yeah. Yeah. So yeah, I know. I get I get I get your hypothetical question. It's a very niche, hypothetical question. And to be honest with you, I have never seen a patient like that. Um, I have seen, like, you'd be like, you know, I don't even think Lucky's the correct word. You'd be quite unlucky if only just those three were affected and the last one would be fine. Um, but yeah, it's a good question. I mean, the main thing that I I just wanted you guys to take away and when it comes to this slide is the fact that if it's in our promoting your lesion, it only affects half the face. Whereas if it's a low emergency release and it affects all of the face because of the fact that when it comes to the upper motor neuron there is There is innovation from both sides of the cerebral cortex. But once you come past the nucleus, all of it's just from one side. That's the main thing. I want everyone. I want everyone to take away from this. As long as everyone's understood that you understood the core principle off this slide, does that make sense? Yeah. Thank you. Yeah. Okay. Great. Fine. Okay. So some practice questions. So everything we could just going through paralysis off the lower face on the left side is suggestive off. What lesion site? Um, and yeah, this anyone? Yeah. So, uh, promoting You're on on which side? Yeah. Yeah. There's also on the chat. Everyone's and, um weight someone. Right? I understand that part. Which part Don't you understand? Then before you go through the rest of the questions, which one don't you understand? But yeah, he's right. Upper motor neuron fibers on who's on tid. Um, I'm just gonna wait for that one person to reply before I continue because I don't want anyone to continue throughout the lecture without understanding everything. Um, the total diagram. Okay. Where in the total diagram. Are you getting confused, or is that just everything in the diagram you're getting confused in? Okay, um, so there's no response. Ah, So should I just continue with the rest of their questions? Sorry. There's a like, Okay. Um, all right. Yes. Continue. Okay, great. Um, fine. So, like, everyone said right up motion, you're on. Um, well done. So so, Like, everything we just gone through, um, so paralysis off the lower face. So as soon as you hear just paralysis of the lower face, you you should be starting to think off. Motor neuron on, then left side. Since it's the left side and it's up a motor neuron, you know, it's the opposite side. If it was the whole face, then you know it's the same side on this Lomotil urine. Great. Okay, so next question uvula deviation to the right hand side is suggestive off. What lesion site? If it's easier. Just just a new one on the, um, in this. Yes, Exactly. Great. Left. Exactly. Great on Walker. Enough Left Vegas now. Perfect. That's exactly what I want to do. It. Vegas now. Okay, so you know, it's the 10th cranial nerve because off the fact that it is the uvula. That's why you know, it's the vagus nerve on you know it is the left because any uvula deviation is to the opposite site. So if it's the right hand side, you know that the lesion is on the left hand side. Great. Okay, so now let's go to tongue deviation to the left hand side. Which cornea? Enough. On which side? The left hand side. Which we're not enough left Hypoglossal. Yeah, left Hypoglossal. Great. Okay, so hypoglossus Oh, the easiest way to Unremar that the tongue is innervated by the hypoglossal. Enough is glossal literally means tongue and then hyper means beneath. So it's beneath the tongue. That's the easiest way. Just remember, the tongue is innervated by the hypoglossal Now on the tongue always goes to the same side. The deviation is on. So it's the left hand side dbs to the left hand side. So yeah, So everyone got that in the end to a lot left type of glaucoma? Yes. Go for just a question. Why would it not? The number nine for the tongue deviation? Yes, hum. So he's so when s so if we just go back to the examination, right? The examination side, it would just go through the number nine issue with the guy angry flex on the swallowing rather than the actual tongue. Okay, Okay. The tongue is the hypoglossus nerve. So that just remember the good that the glass or part really truly refers to tongue. So, like, you've probably heard of, like, macro, um, glossy a right. And that just means big time. Yeah. So that's the easiest way. Does the easiest way to remember. Okay, a good question. Um fine. Okay. So which nerve innovates the lateral rectus muscle of the eye yet? And, uh, he as the addition stuff. Exactly. So the abuse, Um, snuff sixth cranial nerve? Um, yeah. From this question, you can see that I clearly just got the s and l wrong from from when I was talking earlier. Um, please excuse me for that, but I will correct that when it comes to the summary guide. When we send that all final director in any of the slides. If I mentioned as well, um, so great is Thie Abdus and stuff on. The easiest way to remember that is the ab do Abdus and sounds like abduct on the lateral erector. This will abducts the eye. That's the easiest way to all to remember. Great. Okay, on, then. Finally what? Where does the olfactory nerve exit from? So that's going back to a cranial foramina. Um and it's one of the five that I said perform. Play off the ethmoid bone. Very specific answer. Great. Um, so cribriform play? Yeah. Perform play of the ethmoid bone. The only reason why I didn't write off the ethmoid burn is because where does the olfactory nerve exit from can easily be one of your like show on two questions? Um, s a Q v s excuse for, like, anatomy spotters. So I just wanted to keep it to less than four words. That's the only reason. But everyone who all of ethmoid bone very well done our school bonus points for that. Great. Okay, so, um, if everyone could just scan the QR code so that's just a feedback form. And if everyone could fill out the feedback home, that's how we're going to be sending the slides and the summary guide and everything for your own revision. Um, on everyone, please feel free to also follow. Please do follow such shock jazz for future like sessions and updates and everything. Um, sorry. This has been, like such a disk and jointed session because I should have had a second person, but, um, I think something happens. Uh, yeah, I'll just keep that side up. Um, for the time being, what if you cannot scan QR code? If you can ask and think you're Kurd? Um, I will try on. Do get the link. Just give me a second. Um Ah. There will be a recording. Just fill out the feedback form. Um, that should be a recording, I think. I think that's also going by the feedback home. Or it should be on this team. Um jazz. Well, if that if If so, I'm guessing one person just joined a bit late. When did you join? I can try and do just a quick summer of everything we've gone through a lot of five minutes. Um, at what point did you join? If if if you just told me that I can go through it really quickly, you're welcome. Um, okay. And okay, I'm guessing that person, um, by the left or or there's some type of, like, so just wait for that response. Um, thanks. Yeah, yeah. You're welcome. Thank you for everyone for coming. Um, if there's any more questions just asked me, um, please feel free to on me and ask. I will be here for, like, another 10. Also minutes. Um, if they're not anything, just ask, and then I will go through it. I'm more than happy to go through it. Um, I know Crinone obs is a very, very long examination on, but no one really likes doing it. But everyone just has two at one point, um, either to just pass exams or if you are going into, like, emergency medicine. Um, you'll probably be doing a lot of these, or if you do stroke in the future, you probably be doing a lot of these. Uh, I'm guessing their questions from anyone. That's sorry. Do you mind if I just, like, try to explain the diagram to you one time? You Sorry. Using? Yeah. Norris May. Nor is, uh let me go to the diagram on then you You explain away. I will listen. Yeah. Good for Okay. So basically, the main thing that you wanted to say was that if there's an upper motor neuron lesion is only going to affect the lower part of the face because there's always one nerve that's coming from the cerebral cortex that's going to supply like a part of the upper part. And then if it's a lower, is going to affect both because it's like that, all of them. There's a crossing over. So, like all that scientists going to be affected, this thing sort of sort of sources. Algia just rephrase. Exactly. So you understand the Corporates? Well, basically, um, if you're going from upper right, if there's an upper motor neuron relation, there is a two least one part of innovation from the other side. So that's why the upper half is still unaffected. Whereas if you have a lower murder in your election that at the nucleus level everything's like, joined and become the facial nerve at that point, even though that's like three branches or whatever, everything's the facial nerve at that point, right? So that's why it effects, um, the whole half of that face. Does that make sense? Yes, So it's more about the fact that it's leaving after the nucleus rather than like where it starts from. Exactly. Exactly. So if it's Yeah, doesn't make sense. Yeah, that does. That is. Thank you. Great. Perfect. Nor is glad I could help. Okay. Any more questions? I know it was a bit of a diuretic to exception. I I did try and make it as interactive. It's possible. Cranial nerve is just one of those, which is really, really, um, long winded. Um, if anyone has any questions in the future after this or one while watching the recording or summary guide, um, please feel free to email me. Um, yeah, if you have any questions for the other station of the CP is, well, peaceful. Free to email me. Um, teaching is like something I like to do. So yeah, um, I'm guessing normal questions left. Great. Okay, um, and everyone was able to either scan the QR code or get the link from the shot. Right? Okay, great. All right. I will stop sharing. It stopped recording as well