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Ok, so today we're going over um, neurological histories, um, cranial nerves. Um, so we're going to be going through a headache history, going through a case and then going through the actual, um, called for the Os as well as, um, some questions and top tips at the end. Um, so starting off with our history, um, we want to start off just by introducing ourselves normally. Um, and I've just given sort of an example there. Uh and then with the presenting complaint after they've told you why they've come in, um, it could be really good to ask them if they've been offered anything for the pain. Um, and then offer them painkillers if they haven't, um, onto sort of where the bulk of the marks are for the history. So Socrates works incredibly well for headaches. Um, starting off, you know, as soon as you ask them, er, where they tend to feel the pain. If it's unilateral, you can sort of think, ok, migraine cluster. But if it's bilateral um that, and they sort of describe it as like a banding or if it's all over their forehead, um, you can think of a tension headache, um going onto onset. So the red flag to think of here is if it's sudden, you know, think subarachnoid hemorrhage and then sort of ask them what, what it feels like. So if it's pulsating, throbbing, is it sharp? Um I think the, the most uh distinctive one is sort of the electric shock pain from trigeminal neuralgia. Um then, you know, does it move anywhere? So if it moves down to the neck and shoulders, that's usually a tension headache. And that's a really good question to ask if you think it's just a tension headache. Um And if it's sort of, if they describe it more as like neck stiffness, do you consider meningitis? Um And if they have pain spreading to their jaw, that could be temporal arthritis, um then moving on, we have uh so associated symptoms, you sort of need to cater to what you already think it might be. Uh But what is really important to ask is, you know, do they have a teary runny nose, um irritated eyes because that could be a cluster headache. You can also ask them if they've been feeling nauseous at all. Um You can ask them if they've had any viral symptoms. Um For time course, the important red flag to pick up is whether it's worse in the morning or worse when they're laying down cos that can indicate raised intracranial pressure because basically, um you know, if you're lying down the fluid sort of, er, remains there but as soon as you stand up, that can relieve the pain just because, er, the fluids sort of able to drain downwards, then thinking about exacerbating factors, we sort of want to be thinking about our migraine triggers, for example. So that chocolate pneumonic where it's like chocolate and the combined oral contraceptive pill, um, alcohol, lack of sleep. Um, all of those sort of migraine triggers. Um, and also if they say that it's slightly worse with brushing their hair, once again, you want to sort of think about trigeminal neuralgia because that's a very typical sign. Um And finally, with severity, uh just sort of remembering um that because I think they, or at least I didn't quite notice and say year two, just how extremely painful cluster headaches are. So, if they say that it's a 10 out of 10, it's likely to be that um going onto red flags, we've mentioned a few of them the way that I liked to, it was essentially think of the symptoms of meningitis and then um go through those. So nausea, vomiting, rashes, neck stiffness, photophobia. Um That way, you know, especially with photophobia, you're also picking up acute migraine symptom. Um And it's for symptoms that you can sort of get out of the back because, um, you know, realistically you won't be able to uh ask every single question, but this um encapsulates a lot then going onto floors. Um So ask them about fever. Have they been feeling tired? Have they had any appetite? Have they lost any weight? They had any night sweats? Um And basically what you're trying to rule out generally with floors is um cancer. So in this case, a brain tumor, but also it can encapsulate. Um you know, the fever and the just sort of feeling generally ill could encapsulate a viral illness. So again, meningitis and then when you, when you're doing your systems review, um so this is a systems review that I would generally do for um any sorry, any neurology. So you can ask them about any sort of faints, fits or funny turns. So, you know, loss of consciousness, seizures falls. Um and then you can go through each of the five senses. Um So, have they experienced any changes in their vision, any changes in their hearing, any changes in their sort of taste and smell? Um And finally going on to touch, you know, have they had any tingling? Um have they had any loss of sensation? Um have they been feeling weak and then going on sort of through um the cranial nerves? So, cranial nerve eight, have they had any changes in their, in their balance, you know, have they been falling more often? Um And then cranial nerve nine. So just thinking about the throat region, you can ask them, have they had any speech or swallowing issues or again, you can ask them if they've been coughing a lot. So any like viral pathology basically. And then with cranial nerve 10, uh, that can remind you to just ask about any sort of like chest or palpitation symptoms. Um, and also bowel. So have they, you know, have they had any incontinence? And then here I've just sort of listed, um, more specific ways to, um, ask about those, uh, then going on to the rest of the history. So past medical history, you're always gonna ask GP hospital surgery basically, um, drug history. So specifically for a headache, you want to make sure that you are asking, um, if they're taking paracetamol and for how long or how much, because a medication overuse headache is something that could very easily come up and is generally caused, um, by taking thing like really common analgesia, like paracetamol for about more than three months. Um, and if you're suspecting a migraine, it's really key and probably will be like a mark in of itself, um, to ask whether they are taking the oral contraceptive pill. And then of course, ask about allergies with family history, you just want to make sure that you make it a bit more specific. So just ask if anyone in the family experiences regular headaches or whatever sort of headache they seem to be experiencing. And just if there's any sort of neurological or brain issues within the family, then with the social history, the pneumonic that I like to use is Fado, but there's, um, a few others so that I think there's one that's like Lola's diet. Er, but I feel like this one encapsulates the most important things. Um, just in case you are running a bit short of time. So, um, smoking, alcohol, drugs, occupation and then importantly, with a headache history, you sort of want to ask them about sleep stress. What are they eating? Um, just because just a lack of sleep, um because these things can trigger both a migraine or also could be exacerbating like 10 headache. Um And of course, as always, you sort of, you want to integrate your ideas, concerns and expectations throughout. Um and wherever you've sort of found it best in your histories, you, you are going to want to summarize because I think that is marked. Um And then I've just made a table that um people can go through in their own time, just sort of summarizing the types of headaches and their sort of Socrates answers. Uh So moving on, we have a 22 year old woman who's come in with a unilateral deep throbbing headache that has built up over minutes and then reaches peak intensity at the last hours. She feels tired half an hour before the headache and experiences some sensitivity to light. Um Can people just type into the chat? What other questions would they ask her? And what are some red flag questions specifically that they should be asking. Yeah. So someone said uh lack of involvement, that would probably be a good question just to um rule out cluster headaches. Um Anything else? Yeah. So, um we'd want to sort of ask about um timing. So, is it coming on regularly because migraines don't tend to come in isolation? Um We'd want to ask about any other sort of visual aura symptoms. Um We'd want to be asking about triggers. Um You know, uh is she, is she on the pill? For example, um Does she drink a lot of caffeine? Has she ever had anything like this before? And then red, red flag wise? Uh So she's got the photophobia. We might want to ask about nausea, vomiting, rashes, um neck stiffness, that sort of thing. Um And then I think we can all assume that the most likely diagnosis, diagnosis here is migraine. So moving on to the actual cranial nerves exam, you're going to want to start off with the, with the, with just introducing yourself. And I think it's good to just memorize the phrase for each of the Os exams of how you're going to explain what you're doing. And I think it's a bit hard with the cranial nerves exam to sort of summarize that. Um So it's worth sort of just um so, so what I like to say was, hi, I'm Rama. I've been asked to perform a neurological exam on you. This will involve testing your vision hearing and facial expressions. Is that ok? And then occasionally, um in real life, I would also sort of just mention to them. Um you know, so for parts of this exam, uh in order to just sort of uh test your sensation, I, I'll have to touch your face. Is that ok with you? Um Just because that's part of the exam that people might be uncomfortable with if you don't have them a little bit. Um And then when you're positioning yourself for this exam, just make sure that you're knee to knee with the patient, um you don't want to sort of be to the left or to the right and you want to be fairly close to them um just for some of the visual tests to actually work and then don't forget inspection. I think it's really easy to forget with this specific exam. But, you know, before you sit down, do just have a look around the patient. Uh make it really obvious for the Osk examiner. Um And you know, you're inspecting for the same things that you are in the limbs exam. So, scars, wasting involuntary movements, circulations, and tremors. Um And then you might want to ask them if they've noticed any changes in the mirror recently just to make sure that they are at their baseline. So then starting off with the first cranial nerve, we're gonna go er, you literally for the olfactory nerve, easiest nerve. Have you noticed any changes in your sense of smell. Um And then the test that you offer, I would like to um or would you like me to er, test their sense of smell using scented bottles under each nostril separately. And then that's first nerve done. So, moving on to the optic nerve um used as Afroc. Now, Afroc stands for Acuity fields, reflexes, ophthalmoscopy in color, um as in to testing with issue horror plates. So starting off with acuity, um this one's quite easy, you just ask them questions. A lot of this is going to be just speaking to them. So it's best to practice this. It's best to practice your phrasing. So ask them, you know, do you wear glasses or contact lenses and do they know their prescription? Have you noticed any changes in your vision? And then also you'll offer a test. Um I like to offer all the tests at the very end of like sort of having done the earth. So I'll summarize those at the end. Um Then after that go into fields. So you're gonna want to um you want to assess whether they can see each of the four quadrants and also that peripheral vision. So starting off with the four quadrants, you're going to ask the patient to cover the same eye you are covering. So can you cover your, um can you cover the same eye as I am and then um ask them to keep looking at your nose and say yes, when you can see my hand in your field of view and then just go from the corner inwards from the corner inwards and you can stop as soon as they say yes, then switch hands. Um and when you're switching hands, they may be tempted to switch hands. So just let them know to keep their hands um still or in the same position. Um and then switch eyes So, you know, ask them to um cover the other eye and do the same thing, you know, keep looking at my nose and say yes, when you can see my hands. Um And then the uh test that you can offer, there is the blind spot test using the red hat. But again, I tend to like to offer all, all of those at the end. Um So then peripheral um visual inattention with this one, they don't have to cover their eyes just with the patient looking straight at you, hold your arms out to your side and just wriggle one of your hands and ask the patient to point at which hand um has their fingers wriggling. So literally just say, say to the patient um keep looking straight at me or keep looking um sort of at my nose. Um and just point to the hand that is moving and then, you know, go from the top, middle and bottom um moving on to reflexes. So this is where you have the porch and the lighter start off by just looking at the pupils, um look at the size shape symmetry. So um check that their pupils are basically equal and reactive to light and check that they are a normal size. So, are they at their baseline dilated or um constricted? Um And sort of check for things like ptosis, you know, is the eyelid drooping. Um What you're going to do is you're going to take the pen torch and at this point, it might be um useful just to have um the images here. You're going to take the pen toch, you're going to ask them to put their hand in between um their eyes just so that lighter just so that you can control where the light is. Um And then you're going to so shine it into one eye and just make obvious to the examiner that you are first checking for the direct reflex. So I'm shining it into this eye. I'm expecting this eye to this eyes, people to constrict. So I'm looking at this eye and then check the other eye and see if that is restricted. So check if the eye with the light and without the light have restricted, and then you're gonna repeat on the other eye. Um And after that, you're going to want to do the swinging torch test to check for a relative afferent pupillary defect or rapid. So that's just where you, you know, ask them to remove the hand and just swing the light from eye to eye. And if they do have this defect, what you're going to find that they have um is that the affected eye, the eye with the defect will actually dilate in response to the light. Um Yeah, and then after that is the accommodation reflex. So the three reflexes are direct and consensual swinging torch test and accommodation reflex, the accommodation reflex. Um you no longer need the pen torch. You ask the patient to look at the corner of the wall behind you. Um And then look at your finger when you say. So, um you would say, can you look at the um can you look at the corner of the room? And then when I ask you look at my finger, um keep looking at the wall, keep looking at the wall, look at my finger and then you want to see whether their eyes converge and whether their pupils constrict. And at this point, you're going to move your finger slowly inwards um to them. So then the test that you offer at the end um is the Snellen test, red hat. Oh Sorry, the blind spot test and ophthalmoscopy and color testing with the Shaara plas. So you can literally instead of, you know, remembering to offer after each thing, just remember at the end of doing the entirety of the optic nerve. Um Would you like me to do Snellen testing blind spot testing, um ophthalmoscopy or color testing with issue hearts. So, um and this is just the exelon's chart, by the way, in case anyone is unfamiliar and this is the red hat pin test. It's really rare that they ask you to do this. But if they do um it's literally just you cover one eye. Um And you say, um can you tell me when you can no longer see this uh red happen, you'll just move it very slowly. Um The visual field defects, you might want to go over because they do tend to have pathologies in the neurological exams in the osk because it's quite easy to fake them. So generally, what would occur here is you will find, for example, they might have bit and oral hemin and this just means that when you're assessing for peripheral vision defects, they will not be able to like they'll incorrectly point to which, which of your hand is wiggling. Um The same with, er, homo, um homonymous hemianopia, except you'll see that they're only incorrectly pointing on one side. So then uh 34 and six. So you know, the ones that control the movement of the eye, you're gonna want to start off by just again inspecting the eyes. Do they have a squint, do they have ptosis? Do they have a facial drip? Um And then you're gonna wanna do the H test and the H test you can um do with two hands um and ask them before you do the H test. You know, do you have any double vision, blurring any eye pain? Then say, can you just follow the finger that is moving, move it like this in an H pattern? Come back to the middle. Um I'm doing it quite small just so you can see it on the screen. But do you go a bit further? Um And then remember to ask again, was there any pain, double vision or blurring during that? Um Then you're going to watch a test with nystagmus. It's a very similar test. You basically, you just do you ask them to follow your finger just horizontally and downwards? So basically, you're making a cross um and you might actually see nystagmus. So I saw someone who actually did have nystagmus in my exam. So do make sure to actually uh pick up on it. Um Some causes of nystagmus is a question they might ask. So peripheral is BPV, BPPV, vestibular neuritis, acoustic neuroma and essentially it could be stroke, MS or a tumor. Um Just a note, you probably will not see this in your exam. But if they have vertical nystagmus that almost always um indicates like a midbrain ab lesion. Oh sorry, just a midbrain lesion. And this is just to here. So moving on to cranial nerves, um moving on to sort of palsies that you'll see. Um So just going, just remembering the functions of each nerve cranial nerve three. So the oculomotor nerve um innovates pretty much all of the orbital muscles, except for the superior oblique and lateral rectus. Cranial nerve four or the trochlear innovates the lateral rectus. So um it abducts the eye so it moves it outwards um and cranial nerve six innovate superior oblique which so as you can see on this diagram moves the eye like it abducts the eye and depresses it at the same time. So if you have a cranial nerve, three palsy, these two sort of take over and you'll see that the eye is down and out. Um And you can see that here and it sort of just remains there regardless of which way the patient looks with 1/4 nerve palsy. So this is, you know, where the lateral rectus muscle is no longer being innervated. And so the patient can't abduct their eye, so they can't look to the left with their left eye. So, um as you can see, so here it's the patient's right eye that is affected. Um And so they can't really um abduct their eye properly. Um And then finally, with a, oh, sorry about that, I will re label that, but it's the cranial nerve six, which is the obducens is the one that is responsible for abduction in the lateral rectus and cranial nerve. Um four is the one that innervates the superior oblique apologies. So, with the fourth nerve palsy, um it's the superior oblique that's being affected. And so the patient's uh eye can't, it doesn't seem to be able to sort of go down and out. And so you see, when they look right, the eye is actually going up because the super obliques affected and then with the six nerve palsy. So, um the lateral rectus isn't being innovated. It's the abducence that's being affected, they can't abduct their eye. So when they try to look right, the eye that's being affected, just look straight on. Um when they, when they look straight, the eye is actually looking centrally. So, um and then, you know, when they look to the, so when their, but when their eye is trying to look inwards, that's fine cos it's the abduction that is affected but not the abduction. So, moving on to causes of ptosis. Um It's just really important to um remember the difference between a cranial nerve, three palsy and um Horners syndrome. So, with cranial nerve three, with the oculomotor nerve, it has parasympathetic um fibers which will um constrict the eye. So if there's ap that means that you'll see that these are normally dilated as you see in the top image here. Um Whereas in Horner's syndrome, it's affecting the cervical sympathetic um plexus, which means that you can't um dilate the eye. Um And so you'll see that the pupil is abnormally constricted. So with Horners, you'll have anhydrosis and meiosis. Whereas with a cranial nerve three palsy, you'll have mydriasis. And then also you might see that the patient's eye is um sort of down and out. Uh And then if in the rare um event that it is caused by myasthenia gravis, um you'll see that it improves with rest, which you know, implies that it's a muscle issue. So, moving on to the trigeminal nerve, um cranial nerve five, this is responsible for sensation of the face. So it has the ophthalmic region, the maxillary nerve region, mandibular region. Um And so what you're going to want to do is you're going to want to take a cotton wall, um just make sure to thin out the end and then just let them know that you're going to um you're going to touch their face with a cotton wall, ask them to close their eyes and just say yes when they can feel it and then, you know, make sure to do it symmetrically and then just ask them, does it feel the same on both sides? Um I don't think they've ever really asked anyone to do it with a neuro tip. It's quite rare but um if it's there do use it just to test a shot touch as well. Um Motor function of the trigeminal is er to do with mastication. So you're going to ask them to clench their jaw and then you're going to want to palpate their temporalis. So here and also their master moss also here has their clenching their jaw and of course, just let them know that you're going to be um touching their face. Um, and the second thing you wanna, you're gonna want to do is, um, so again, ask them to sort of like close their mouth, sorry, ask them to, you know, have their mouth closed and then just say, can you open your mouth against me, um, and just place your hand underneath and try and push up against the opening movements. And um in a normal healthy person, they should be, you should be able to feel quite strongly that sort of their resistance. Finally, you're gonna want to offer these two tests. They very, very rarely make you do it. So, um you literally just say, um would you like me to test jaw jerk or corneal reflexes? And they'll usually say no. But if they say yes, the jaw jerk, you take a tendon hammer, just make sure to have your two fingers here on the chin and just tap corneal reflex, just take a bit of cotton wool. Um take it as close to the eye as possible and see if they blink. And generally, they should have a bit of a blinking and tearing reflex. Um If there's a pathology, you might see that they have a really brisk ge reflex, which would imply a upper motor neurine lesion um moving on to the facial nerve. So the facial nerve is um responsible er for some of the taste in your tongue. So if you remember from your anatomy lectures, the facial nerve is responsible for taste in the first two thirds. And then the trigeminal is responsible for um sensation of the tongue in the anterior two thirds. So you just have to ask them, have you had any changes in your sense of taste moving on to motor, which is the main function of the facial nerve? Um There are four things you ask them to do. You ask them to raise their eyebrows, close their eyes, puff out their cheeks and just sort of smile as wide as they can. Um, and you can do this with, um, sorry, you can do this without resistance and then with resistance. So if you're doing it with resistance, just as they're raising their eyebrows, put your hands, um, just here just above their eyebrows and try and sort of stop them from doing that, try and sort of stop them from closing their eyes. Um, I've had some, uh, some sort of like f ones tell me that it's best really not to do it with resistance because it is very intrusive to try and make sure that someone can't open their eyes. Um, so you don't, you don't have to do it with resistance. Um I think it's best to sort of just ask them to do, uh, just ask them to raise their eyebrows and close their eyes normally. Finally just sort of the signs of a of a facial nerve palsy. So, um as you're probably familiar with, if it is a lower motor neuron lesion, so Bell's palsy, you're actually entire face droop, um sort of weakness of all muscles on the its lateral side. Um And I've just attached a diagram here so you can sort of see how that works, but essentially the upper part of the face is innervated by um multiple branches, whereas the lower part of the face only has sort of one branch moving to it. Um So if you have an upper motor neurone lesion, you'll find that it is still innovated by the um like the top part of your face will still be innervated by the other side. And so you'll only have weakness of muscles on the interlateral side, but it'll be forehead sparing. Um So the summary of all of that is if they have Bell's palsy, the entire um half of their face droops, but if it's an upper motor neurone lesion, only the bottom half on one side will droop moving on to hearing. So, starting off with just a crude hearing test, um people do this in different ways, but the way that I have found easiest is if you wriggle your fingers by one ear just to sort of distract that ear and then whisper in the ear that you're testing and just ask them to repeat a number. So you might just say, you know, like 97 and then just ask them to repeat it and then do the same in the other ear, wriggle to distract the, um, the ear and then whisper in the other ear a number and ask them to repeat it. Um, and it's best to sort of do this from behind just so that they can't lip read. Um, then ask them if they've had any changes in their hearing and if they wear any hearing aids. So it's the same as with the optic nerve. Um, do you wear any glasses? Have you had any changes in your vision? Moving on special hearing tests, Winnie's and Webers. Um, I think for time they tend not to actually ask you to do this, but you at least have to offer and you didn't have to know how they sort of work and they might also ask, um, or at least II was specifically asked, what is the tuning fork? So you need to know that it's a, it's a 512 tuning fork. The other one is the 1281 which we'll use for limbs. So place your 512 tuning fork on the bony part behind the ear. So, on the mastoid process, um, after having sort of whacked it somewhere, I like to whack it on a table. Some people whack it, um, sort of on themselves. Some people are able to do it manually. I think the easiest thing is just whack it on a table. Um, yep. Then put it on the bony process behind that ear and ask them, can you hear it now if they say yes, let me know when it stops and then they'll say, ok, well, stop now, move it in front of the air. Um, and at this point, they should be able to hear it, um, because like their air should be able, sorry, their air conduction should be better than their bone conduction. If after you place it in front of their air, they can no longer, they, they still can't hear it. That implies that their bone conduction is better than their air conduction. And if you have better bone conduction than air conduction, that will imply that you have conductive hearing loss. Um So just to clarify again, what would normally happen is that after you move it from their mastoid process and put it in front of their ear, they can hear the sound again and that's normal or if they have hearing loss, it would imply that at the very least the hearing loss that they have the sensory neural hearing loss. Um So next, we have Webers, uh what you're gonna do that is you're going to take the training fork, you're gonna put it the base of the training fork right on their forehead. Um And you're gonna say you're just gonna ask them, can you hear it? Can you hear it equally on both sides. Um And with Weber's test, you have to do first because you need to know if they have hearing loss, whether it's conductive or sensory neural with Weber's test, it's just going to tell you which of the ear has the issue. So if they have sensory neural hearing loss, then it will be um louder in the normal ear, sort of sort of as you expect, they can hear better um in the ear without the hearing loss. Whereas with conductive hearing loss, you're actually, it's gonna be your ear with the hearing loss that hears um those vibrations better. And the reason for that is because if you've had conductive hearing loss for a little bit, your bone conduction in that affected ear is gonna be better. And also because you can't conduct sound into your ear as well, there's reduced like noise pollution. So with conductive hearing loss, they're actually gonna hear better in the ear that's affected. Um This is just a summary image. Um And finally, the test that you offer for vestibular cochlear um for testing cranial of eight is test their balance, um offer RR and Webers and also you can offer autoscopy and audiometry for hearing loss. So moving on to the mouth, I've sort of put together the glossopharyngeal vagus and hypoglossal nerves because um they all happen in the same area and it saves a lot of time. So you start off with um assessing the uvula. So all you have to do is, um, ask them to open their mouth and say, ah, and just look at the uvula, see if it's deviated. Then for, um, cranial nerve 12. So for the hy, the hypoglossal, the one that innervates the tongue, ask them to stick their tongue out and that both has the function of, um, your testing, you know, their motor, er, their motor function. So can they stick their tongue out? And then also you can assess for wasting and fasciculation, then ask them to push their tongue against their cheek. You can also ask them to do this against resistance. So just pushing against their tongue and finally, just ask them to say baby hippopotamus or British constitution just to sort of test their um speech if they have an issue. Um Well, if it's um if it's their uvula, it's gonna deviate towards uh it's gonna deviate contralaterally to the lesion. Um So basically, if the uvea is deviated, uh right, then it's the left um glossopharyngeal that has an issue with the tongue, it's going to deviate its laterally to the lesion. Um So, uh if it's deviating left, it'll be a left issue. Um And you also see muscle wasting on the ipsilateral side as well. And this image here is just showing this uvula deviated. Um And this sort of is summarizing some of the signs that you'll see. And finally, with um cranial nerves nine and 10, the tests that you want to offer are a swallow cough and gag reflux. Um And if they actually ask you to do any of these, which I actually did get asked to do them, all you have to do is ask them to swallow or to cough. Um, they will never ask you to do the gag reflex. So, don't worry about that. Um Finally, we have the accessory nerve. So cranial nerve 11 innervates the sternocleidomastoid muscle, which allows you to sort of turn your head properly. And also the trapezius muscle, which allows you to raise your shoulders up and down. Um You're gonna start off by sort of just once again inspecting this general area. Is there any wasting any circulations, any sort of asymmetry in the muscle mass? And then you're going to want to assess their motor function. So, um up to you, the order that you want to do these two in uh but you can start off with the trapezius and just ask them to shrug their shoulders against resistance. So, say, OK, I'm going to put my hand on your shoulders and can you just push your shoulders up against me? Um And just try and do it at the same time so that you can feel any differences. Um And then with the sternocleidomastoid muscle, you're gonna want them to ask, you're going to want to ask them to turn their head against resistance. So, um say, OK, I'm going to put my hand against your cheek now. And I'd just like you to, um, to, to turn your head against my hand and then again, ask them to turn, um, the head against your hand. Um, and normally you should be able to feel, you know, quite, quite a lot of resistance to your hand movement. And then finally, when you want to finish the exam, you're going to summarize and you're going to go through, um you're going to try and go through all of the nerves. Uh you can sort of um you can lump a lot of the normal ones in together. So if it was a completely normal exam, you can say examination of all 12 cranial nerves was unremarkable. Um Things to note are generally with any exam you'll say on general inspection, patient appeared comfortable at rest mentioned that they had normal speech. Um you know, they had no stigmata of neurological disease and no objects or medical equipment around the bed of relevance. And then once you've done that, you can then state any pathologies. So if for example, you think they had a visual field defect, um you can state that here, say examination of all other cranial nerves was unremarkable and then finish off with, in summary, these findings are consistent with and then whatever pathology you think it is. So right, homonymous hemin or bit and pleural hemin or whatever or Bell's palsy, whatever else you may have found. Um And finally finishing off the tests that you will offer are, you know, I would like to now perform the following assessments and investigations. Um, a full neurological examination of upper and lower limbs, a mini mental state exam. I'd like to test gait and balance and at this point you can put in any other exams or reflexes. You forgot. So, if you, if you are thinking, oh God, I forgot the Georgia and corneal, um reflexes, then you can put that in here. And if you think that further investigations are warranted. So if, if, if it's a completely normal exam, you might not necessarily want to mention that you'd like to do an MRI. But if you think that um something is wrong, you can say, well, I'd like to do um an MRI because I'm concerned about X. Um And if you think that they had some hearing loss. So if they, for example, purposely failed the crude hearing assessment because it's an ay, so they won't actually have an issue, but it's very easy to fake hearing loss. Um You can request formal hearing assessment such as audiometry. So then going on to uh some questions uh starting off, can someone just put in the chart? Basically, if someone is, is presenting with pupil mydriasis and the pupil seems to be down and out the ptosis, what is the likely cause of the ptosis? And I'll give that just a minute. Um So with Horners syndrome would, you, you would tend to see pupil meiosis. So the pupil constricts. So Horners syndrome is due to, for example, a pancoast tumor pressing on the cervical sympathetic plexus. And that cervical sympathetic plexus leads to the sympathetic innervation of the eye. Normally sympathetic innervation, you dilate the eye, you know, you want to be sort of wide awake for any danger. And so when that's cut, you get pupil constriction. So with Horners syndrome, you're going to get pupils constriction um as well as anhydrosis. So um it's meiosis and anhydrosis, it's ptosis, miosis and hidrosis that you get with Horners syndrome. Um So do you want to try another answer? Yeah. So someone's put a um yeah. So it's, it's gonna be a surgical um cranial nerve three palsy. So, dating between a surgical and a medical um oculomotor palsy with a medical one which tends to be caused by say, ischemia, your pupil is spared, you won't get the pupil mydriasis. And the reason is because the it is the outer part of the nerve of the oculomotor nerve that carries parasympathetic fibers. So, as long as those outer parasympathetic fibers aren't affected, you won't have um like abnormal dilatation of the pupil with a surgical cranial with a surgical um cranial nerve, three palsy, uh the outer part of the nerve is sort of is cut or compressed or whatever has happened to it. Um And so the parasympathetic fibers are affected. And so there is papillary involvement. Um And obviously, if you cut the parasympathetic fibers, um then the pupil will dilate, sorry that I think I've written constricted here, but it will dilate because you no longer have the um parasympathetic function of constricting the people. Um Second question. So a patient states that they've experienced some changes in their hearing. So you perform A's and Webers, the Rin's test comes out positive I would like to state because I think I didn't state it before. A Rin's positive test means that, that, that they had that it is normal. It's, it's a good thing as opposed to what it normally means. So if it's Ren's positive, that means that they have um you know, a physiological normal healthy result. So the Rin's test was positive on both sides, but Weber's test reveals that the hearing loss is worse on the right side. What is the pathology? And I'll give that one a minute because I think, I mean, I personally always get a bit confused with runs and Webers. Um And I think that's a good reason. They don't really tend to use it clinically. So someone's put, it is a lot of words. Yeah, I think Rennie's and we, it's quite confusing. Um I'll start talking through it. So if someone is, if it's rings test positive in both ears, that means that the air conduction is better than the bone conduction, which is good. That's great. Your air conduction should be better than your bone conduction. Um So that means that there's no conductive hearing loss if the Weber test then reveals that, that um when he says conducted. No. So, so I'll go back to the slide because it is quite confusing. OK. So if can you see my cursor? Yeah, you can. So the RS test, you place the um the tuning fork on no asterid process. So on the sort of bony region just here. Um you, you, you make it vibrate and then you place it here and you ask them to let you know when they can no longer hear it and then you place it in front of their ear and normally they should be able to then hear it again once you've placed it in front of their ear because your ear should conduct better here. So air conduction here should be better than bone conduction. So, Rin's test positive means means that what I what I just explained where your air can, where they can still hear it if you move it in front of the air. So the air conduction is better than bone conduction. So Rin's test positive means that they either have a healthy ear. Basically, Rin's test positive means that they don't have conductive hearing loss, I think is the way to think about it. Sorry. So with this question here, if Britney's test has come out positive on both sides, that means that they have no conductive hearing loss, if the web is test, which is where you place the tuning fork on your, on their forehead and then you ask them, you know, can they hear it equally on both sides? And this person said no, II can't hear it quite as well on my right side. So Rin's test has told us it's not conductive hearing loss. And then Weber's Test has told us they do have some hearing loss. But on their right side, that means that their hearing loss, if it's not conductive, must be sensorineural and with sensorineural hearing loss, um they will hear things worse in, sorry, with Weber's test, they'll hear it worse in the affected ear. So here they have sensorineural hearing loss and with Weber's test, it's worse on the right side. And that means that it's right sided, sensorineural hearing loss. Um Does that sort of make sense? I know that it's really, it's really hard to, to get your head around, but basically Renny's positive means that they don't have conductive hearing loss. And the Weber's test just tells you, you know, which ear can pick up vibrations better and that's, that's basically running and wes. Um So this is the final question. Um Yeah, no worries. Uh So the patient does not seem to be able to. So this is, uh imagine that you are that you are performing a cranial nerves exam. And what you found is that the patient isn't able to see your fingers move during peripheral inattention, peripheral intention. Is, is this exam here? Sorry, I've just, it's this exam here where you, like, um, ask them to look straight at you and then point at which, um, like which finger is moving. So on the peripheral attention side, they like, can't seem to see your hand when it's moving on their right side. Um, and then when you inspect their pupils, you see that one is actually asymmetrically dilated at rest. Um When you do a H test, you then see that the right eye isn't really able to adapt or to look up. Um So their right eye is kind of down and out. And then when you um test their sensation, you see that the cotton wall, they can't really feel any cotton wall near their eyes. Um And finally, when you sort of check the motor in the face, tongue, neck and shoulders, it's all normal. Can you type into the chat, which nerves are affected, like which is like which nerves seem to be having issues? Um And I'll give you, I'll give you a couple of minutes to that for that because I think you need to sort of reread the text and just um try and match up each issue with a cranial nerve, basically three and four. So for is the trochlear, so it controls the superior oblique and the superior oblique brings your eye down and out. So if this person is um, this person, basically, their eye is down and out, they can do down and out, but they can't look up and, um, sort of bring the right in as well. Yeah. So someone's put oculomotor nerve, definitely the oculomotor nerve because this person can't really look down and out. Um, yeah, so not for, um, cranial nerve six is the Abducens. So if they had a cranial nerve six palsy, they wouldn't be able to use their abducence. So they wouldn't be able to abduct. So they wouldn't be able to look like away basically to look laterally. So not four and yeah, not, not six either. Um So, yeah, they have a cranial nerve three palsy also, not just because their eye is unable to, not only because their eye is down and out, but also because it's asymmetrically. So it's dilated. So um that implies that the parasympathetic innervation to the eye is also being affected. Um So definitely cranial nerve three, can we come up with one more nerve that might be affected? Um So if they can't see on the right side as well, so if they can't see on the right side, they probably have a right sided optic nerve lesion. Um Oh sorry, a left, it would actually be on the left side, but they have um right, homonymous hemin basically. Um due to an optic nerve lesion, they have an oculomotor nerve lesion. Um if they can't feel the cotton wall near their eyes, that implies that they have a trigeminal issue, but specifically just in the ophthalmic um branch because they are fine with their cheek and jaw. And if they can move their face, their tongue, their neck and their shoulders, then that implies that they have a normal cranial nerve seven, cranial nerve 12, and cranial nerve 11. Um Finally, just with some top tips with this station, I would say that um communication is key. So you want to sort of practice your exact phrasing just to make sure that patients are understand your instructions and are responding the way that you assume they will. So if you say one thing you want them to to do that exact thing, um stack up the tests that need to be offered to save time. So I've put all of the tests that need to be offered in sort of orange and just so that you can say them at the very end after you've done all of the testing for that nerve, just say, would you like me to do swallow cough and gag? You know, don't, don't split them up because they take a lot of time. Um If you forget any tests, you can just mention them at the end. And also just know that most signs that patients will have will be something that can be faked in a nosy. In in fact, all signs that a patient will present with in an osk have to be something that can be faked. So it will generally be a visual field defect, loss of sensation or weakness. Um Thank you very much for coming. Please fill in the feedback form and um I'll be back, I'll be uh here just for a little bit in case anyone has any questions. Um Alternatively, you can also email me at, er, I'll type it into the chart actually. So thank you guys very much. I'll hang around just for a minute or two in case there are any questions on the chat. Uh but if you don't manage to ask her, you can also just email me. Um Thank you very much. Thanks for coming. Have a good evening guys and please do fill in the feedback form if you can. Thank you. No worries. Thank you.