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So with the cranial nerves station, the session won't take the full two hours. Maybe about an hour and a half. When you when you're given the cranial nerve station in a Noski, it's really unlikely that they're going to ask you to examine Ultram cranial nerves. It's a lot more likely that they're going to maybe ask you to do the first six for the last six or maybe to skip some up. So just be careful when you're reading. The question is which ones they want you to examine. Every medical school is different and every off ski sort of different, but it will be very unlikely that they'll get you to do all of them. Just just one thing. So I'll solve just by running through the cranial nerves. I know most of you know them, and all of you will have some great ways to remember them. Eso the first one, the olfactory nerve. Then we have the optic nerve, the ocular motor nerve, the trochlea nerve, the trigeminal abdu. Since the facial nerve, the vestibular, a calculator, the glossopharyngeal, the vagus nerve on the accessory or spinal accessory. However you want to refer to it and finally we have the hypoglossal on it. So there's 12 of them in total on D. I know loads of you will have a lot of new Monix. You're free to put them in the chapped provided their relatively PG to help everyone to remember them. The new Monica I've gone four is who to touch and feel very good. Valve it heaven or such heaven, if you call it the spinal accessory Nerve. Um, all the new Monix a great just pick one that works for you. Um, I'm gonna try and put a laser pointer on here. So the first four, just some very, very brief anatomy arise from above the ponds from the three broom. The second four will our exit at the ponds on. Then the last four exits were in the medulla solve below the pons. So just a very brief thing. They won't really test you too much on the anatomy in the office, Keystone a shin. But I get to grips with it for your other exams as well. So when we're trying to remember the functions of the cranial nerves, um, I have a group them whether they're sensory, their motor or they're both, um so the Monica got for that is some say merry money, But my big brother said, Well, my brother says big brains matter more. I'm sure you've all got your only Monix for that as well. So if we go briefly through, the function's off the cranial nerves. Three. A factor in earth focuses on smell the optic nerve, mainly site uh, the ocular motor nerve. That will be your eye movement mainly using superior, active in fear actors, media, reckless and inferior oblique muscles. They're also you, um, innovates for constriction accommodation and helps open your eyelids. The truck enough is involved in i movement, so it's for superior oblique Only the trigeminal nerve is involved in mastication facial sensation on sensation to the anterior two thirds of the tongue. But it also is involved in the dampening of loud noises via the tens of Simponi. And then you do since nerve again and is one of the eye movement nerves on. It mainly controls the lateral rectus muscle. The facial nerve has a few few functions, so facial movement and taste, So it's a special sensation from the anterior two thirds of the tongue it also controls like remission, salivation I lived closing and auditory volume modulation via the stupid ius. Then we've got the vestibular calculi nerve, which is involved in hearing and balance the glossopharyngeal. So that's taste and sensation from the posterior two thirds of the tongue azelas following. It also monitors the carotid body, chemo and barrel receptors on the vagus nerve is your main parasympathetic supply to your throat. Abdominal viscera on again? That's also AIDS and swallowing soft palate elevation. The cough reflex on it monitors the aortic arch body chemo and the aortic arch, chemo and barrel receptors. So Glossopharyngeal was for the carotid body. Chemo embarrass. EPT is where is the vagus nerves for the ones in the aortic arch? Um, then the accessory nerve is involved in turning your head on shrinking your shoulders on. Then finally, your hypoglossal neighbors mainly involved in tongue movement. This is an exhaustive list of the functions, but these are just the main ones for you to remember to help you, to identify pathology on if something's going wrong during the examination, and there's a little drawing that I'm sure you've seen before on the Internet, that sort of tries to highlight these nerves and what they do here, I've really poorly drawn it. You'll find it much better out there, but your factor. You know where the nose is. Optic nerve, Where the eye where the pupils are to do eye sight than 34 and six for the eye movement. Five for your face is where the seven, the facial nerve and then you've got cranial nerve eight by your ears as your vestibular cochlea. Nine forms your tongue so we've said for swallowing and things. Azelastine 11. Your accessory nerve by your shoulders on day 12 Again the tongue movement for hypoglossal. So here's what you'll need for the station. This is and everything you need, but this is most likely what you'll be given. You need a pen torch, Snowden chart or what you're most likely recognizes. Saw the I tried that you see similar to the ones in the opticians, but not exactly the same on issue horror plate that will be used to test color vision. A tuning fork, probably a 512 hurts some wall in a neurotic. You might also optionally need another sample scope. It's of migrating eye drops If you're going to do some of my MS Potpie in station on day to fully test one of the nerves, you might need the glass of water as well. So as with all the examination stuff with your general introduction, wash your hands. Don't some people. If it's appropriate, introduce yourself to the patient. Include your name and your also Hello, my name is and I am then confirmed the patient's name and date of birth. Give them a brief explanation of what you're about to do so for the cranial nerves examination, I like to say I've been asked to examine your cranial nerves. These are the nerves that will supply to your head and neck. Now, of course, if you try to talk to them through everything you're going to do, you're gonna be there for quite a while. So I recognize, sent and sort of at the start to say I'll explain the specific details of the examination as I go along on, if there are any issues, we can discuss them later, then make sure you get consent or permission from your patients or verbalize that and then position your patient ready for the examination for this examination should have your patient sort of about one me 1 m away from you. And you should call of trying to be seated with the rise of the roughly the same level. So start off with some general inspection. So, um, look for any speech abnormalities this could indicates, um glossopharyngeal, uh, vagus nerve pathology. Any facial asymmetry? So any facial nerve palsy? He's eyelid abnormalities. So if you got any Tosis, that could be a knock your motor nerve pathology pupillary abnormalities again. They could be ocular motor nerve pathologies as well. Look for any muscle or limb weakness, Any wasting tremors or for circulations, Um, you might also in the eyes gets, um, strabismus. That's squint more commonly known. That could be that your oculomotor your drop your ear or abuse this nerve on, then look for this sort of any objects around the patient that there's gonna give you a general idea of what their baseline is. So any walking or hearing aids, or any visual aids or any prescriptions that they've got around the So if we start with, I find the best way for the original of examination is you just start with cranial nerve. One on finish up the cranial nerve. 12. A couple of them. You might want a group because they're quite similar in the middle, but that way you won't forget anything. So for factory nerve, cranial nerve one, it's really easy. Just assess both the nostrils briefly. Any obvious signs of polyps or blockages was in the nostrils. Make note of that to Examiner, and then ask the patient, Have they noticed any changes in their smell or any loss of smells? That's and so on Osymia. You can formally test or faction using sort of different orders and missiles to the University of Pennsylvania Smell identification test. But it's really unlikely that you're going to be required to do this in a Noski. So just asking the patient any changes they've noticed will be sufficient on. There's various range of pathologies you can get for the olfactory nerve. You can get mucus blocking the nose on that. I'll just prevent the your orders from reaching the receptors. Nasal polyps. These are sort of soft, painless growth. The patient might not have noticed. Head trauma can cause sharing of the A factory nerve fibers. Some people have congenital anosmia on Parkinson's disease. That means also on early feature age infection and more recently as well. We know Covert 19 has been noted to cause transient and asthma. So if we move on to print on nerve, too, and that's your optic nerve now this has quite a few things for us to do, so I'll go through it. But slowly start with the general inspection of the eye. Look at the pupil size now that could very depending on the lighting in cetera and infants will tend to have smaller pupils and then adolescence. Get a look at the people shape. Sorry on day should just solve the rep that people should be nice and round any of normal shapes. Convict congenital of you to pathology. For example, A peaked people is a cardinal sign of a ruptured globe. And then look at people symmetry. So compare both ice. If there's any asymmetry in the pupil size that's called an issue. Korea, Um, but not too important. Remember that word? Then move on to visual acuity. So this is where you're going to use your smell and chopped. So if a patient wears glasses, tell them to keep wearing the glasses. We're not testing their eyesight. A such we're testing just the visual acuity on place the child roughly 6 m away from the patient. Get them to cover one eye and read the lowest line they can read on. Then repeat it with the other. I get them to cover the other eye. When you're coming to record it, just report the chart distance, so that will be a standard of 6 m divided with the numerator and the vomiting. So just put the lower the number of the lowest line they could read. If they get anything more than two letters incorrect on the line, then the line above that is the best line they've read. If they get exactly to you, can record the lowest that is the lowest line, and then you put a minus two. So the exclusion criteria for a line is more than two letters in correct. With some patients, it might be necessary for you to use a pin hole to prove their visual acuity and eliminate the refractive component. You might then need to reduce the distance to 3 m down to 1 m, and, if necessary, get patients just to count your fingers if they can see any hand movements or if they can see like a tall. But those have been very extreme circumstances. Um, pathology. With visual acuity, you might get the refractive errors in people's eye sight. Those could be corrected by getting the patient to look at the chart threw up. In whole, you get amblyopia, which is an ace lazy eye, and that's just the brain failing to fully processed inputs from one eye on it all over time. Start to favor the other eye. You can have cataract cornea of scarring, age related macular degeneration. You could get very commonly optic neuritis, a zero lot of msde I A BT's mellitus and or syphilis, and this is a pathology where you might get really lateral decrease in visual acuity over hours or days on. Then they could also be lesions in the higher visual pathways that caused this and that causes reduce visual acuity, that is, then we're gonna examine the patient's color vision, so this is going to involve the issue horror place over here. So most of you, I hope, can make out a number nine sort of within that. So what you want to do is you ask the patient to cover one eye again and ask them to read the number. Usually the first place, just the test plate on. That doesn't really test color vision that just tests sensitivity to contrast. And then document the number of plates identified correctly included in the test late and then repeat that for the other eye commonly will get pathology. With this due to optic neuritis, you get sort of read the saturation on also commonly a vitamin A a severe vitamin. A deficiency can cause problems with color vision. Um, so this is just a diagram that I've drawn That roughly explains how the pupil a reflex will work so you'll get sensory input trunk from the light source over here on. That's going to be transmitted from the retina along the optic nerve crossing at the optic chiasm. Over here. I've just drawn just one side for simplicity. Um, on then that will go to what's called the pretectal nucleus at the back they're on. That's in the mid brain. Then you'll get motor output from the pretectal nucleus to the wedding. Go west file nuclear on both sides of the brain. So it goes from from just one pretectal nucleus to both adding Go west found nuclear vice um, Interneuron. And then each. Edinger. Westphal Nucleus gives rise to different nerves on the nerve fibers, which are parasympathetic, and they'll travel in the ocular motor nerve to innovate if I go back the celery muscles to let to innovate the celery sphincter to enable pupillary constriction. Technically, it's the short celery nerve that will cause the constriction, but it's controlled mainly by the path and pathetic fibers of the ocular motor nerve. So your optic nerve is your Afrin and your oculomotor ocular motor nerve is your effort is your e factor. So the pupillary reflex What you want to do is you're gonna ask your patient to put their hand between both of their eyes that will be mainly involved in the swing test you could, but it just sort of helps you to differentiate between direct and consensual reflexes, and ideally, you want to have them lights. So the direct reflex what you want to do is shining the light from a pen torch into the patients. People don't hold it for there for too long will become uncomfortable. But just observe the hips, the lateral I like the I your shining the light in on book for people construction that's testing your Afrin on your Ferren. The consensual pupillary reflects involves you shining the light from the pen torching to the patients. I observed the contralateral. So for the direct one. If you shine the light in the right eye, keep looking at the right eye for people construction for the consensual one. If you shine the torch in the right eye, look at their left eye people for people construction, and that's mainly just testing your ephedrine. Ocular motor nerve. Then you have the swinging like to test on day. That's when the when your commonly see where on sort of TV shows, where you move the pen Tort rapidly between both pupils on. Finally, you want to ask the patient to test their accommodation so you ask the patient to focus on a distant object, then switch to focus thing on your nearby finger, which I'd maybe put it 30 centimeters away on. You should see their pupils constrict bilaterally and conversion your finger. So get him to look at the wall behind you and then to focus back on your finger on. That's just testing the accommodation. So just to summarize that slide the direct people a reflex assesses the Seattle Afrin thrill, um, on the PSA lateral. A fur into different limb of the pathway the consensual people reflects assesses the contralateral different limb of the pathway on the swing. Light test will be used to detect relative afferent limb defects, and I'll explain that further on now. So are a P D or relative afferent Pupillary defect, also known as a Marcus Gun pupil, is when one of the optic nerves is damaged. Both pupils will therefore constrict less when light is shown into this affected eye. So that's your affair and part of the disease. It's the optic nerve. One of them is damaged on a sulfa. Both of people's will constrict less when like to Sean into this eye so that people will appear to both peoples were appear to dilate relatively to each other when swinging the light from the healthy I to the affected one. So when the Afrin limb in the optic nerve is damaged partially or completely, both peoples will constrict less when the light is shining to the affected. I compared to the healthy one on the pupil is therefore appear to relatively dilate, when in fact they're actually just constricting less so. Imagine if you're trying to get into your healthy I both people going to constrict quite a bit. And then if you shine it into your affected eye, the pupils are not going to constrict as much. So when you're swinging the torch between both eyes, it's going to make it look like the pupils are dilating in between when in fact it's just because they're not constricting. Um, and this could be due to significant retinal damage in the affected. I could be sent secondary to central retinal artery or vein occlusion on a large retinal detachment or significant optic neuropathy. Such a zombie taking writers unilateral advance glucoma on a compression secondary to any tumors or abscesses. Yeah, you linger a unilateral F E fair in today defect. So this is due to extrinsic compression of the ocular motor nerve, and you lose the different limb of it's a little pupillary reflexes. Sorry, so the result will be the ipsilateral people is dilated on non responsive to light entering either I. So there's loss of celery stink two functions. That's a problem with your ocular motor. Know I know where the optic nerve, but you'll see that there's quite a lot of overlap. Um, so there won't be an issue if the lesions at the optic chiasm because there's bilateral innovation, from the pretectal nuclei to the Edinger Westphal nuclear. But when there's a problem in the it's a lateral frontal. Um, that's your oculomotor that people won't dilate in response to light entering either that same eye or either both ice. So those are your pupil. A reflex pathologies relative afferent pupillary defect on unilateral fair into defects The first one of these is quite more common in your second one, so the next part of the optic nerve examination is visual neglect. So what you want to do is sit your pace it directly opposite the patient at about 1 m distance. So that's your start position, where we're at before and ask the patient to focus on a part of your face. Usually the nose is a good one, and then hold out your hands laterally, then take turns with wriggling your finger on. Ask the patient to identify which hand is triggering. So if I just hold them in a bit closer for the camera, you do. You want to hold them up further out. Wiggle your right hand. They'll tell you the right hand well, your left. They'll tell you the left and then do both at the end simultaneously, and they should notice both. Now it's important to stress your patient that they don't lose focus from focusing just on your nose and that they don't turn their head. They're going to want to turn their head. It's a bit of a tricky one to test, but you want to test it with them, focusing just one specific point on you know, on your face, usually your nose for pathology of this, it's not actually an optic nerve pathology. It's usually due to prior to love injury after a stroke, and it results in ability to perceive or process stimuli from once on, usually on one side of the body. The side of the visual field that has affected is usually contralateral to the location of the parietal lesion. So if they have a parietal region on the left, they probably won't be able to have that. They also have visual neglect on the right, and they won't notice your finger wiggling on there. Right? And then visual fields and blind spots are mainly the last thing for the optic nerve. So against it, directly opposite the patient, a 1 m distance asked them to cover one eye with their hand on you mirror the eye that the patient is covered. So if they have it there left, you're going to have to cover your right, um, on. Then ask the patient to focus again on the part of your face, usually your nose, and then start a regular finger, moving it in slowly from the periphery slowly towards the center and ask the patient to report when they first see it. Report. Repeat this process for each visual quadrant, so stop there. So chance to make these if yourself go all the way around before conference and then repeat that all again for the other eye, asking them to cover it and you make sure you hear the eye that's covered. What you want to do is ensure that you go fingers Equity estimate from you on the patient on if you are able to see the target, but the patient can't see the target. This usually suggest that the patient has a reduced visual field and then blind spots again. You want to sit the patient directly opposite you had a 1 m distance, asked them to cover one eye with their hand and again cover that mirror, the either being covered and cover it yourself. Ask them to pass a patient to focus on a part of your face on using the red. Happen in order for it the red end of a pencil. You want to assess this blind spot, so put it at unequal distance between you and the patient on move it laterally. The disappearance of the happened should occur at the similar points for you on the patient, so the red happen saw disappear and then reappear after it's out of the blind spot. That point at which the patient reports that happen reappearing should also be similar to the point at which it reappears for you. So you're testing the patient's visual fields on their blind spots relative to your own and then just a bit of a brief physiology for the visual fields. So you've got your right and your left eye balls there. Um, you've got the optic nerve on the cross that the optic chiasm on, um, sign ups in the lateral geniculate body on go on. The optic tracks the upset track, this sort of two parts to it. So the outer gray line in this diagram is the myelin on. These fibers correspond to the lower retina on. They receive stimulation from the upper half of the visual field. Unpasteurized, the temporal lobe, the in a gray line. You can sort of see the diagrams on. The best story is the dorsal optic radiation on the fibers there correspond to the upper retina, which mean they receive stimulation from the lower half of the visual field. On they will pass through the parietal lobe. It's a bit tricky to remember, but if you remember, the word pits parietal inferior. So the ones that passed through your parietal lobe get stimulation from the lower half of the inferior half of the visual fields. Temporal superior. The fibers that past with the temporal lobe will get stimulation from the upper or superior half of the visual fields, so pits is the one to remember there. So here's some pathology is that you'll get again. So the diagrams a bit small, but I hope you guys can see that. Okay, if there's a lesion to occur here. A, you'll get what's called left anopia. Now this is mono ocular one I vision loss. Total loss of vision in one eye. Second to the optic nerve pathology, these could be things such as anterior ischemic optic neuropathy or ocular diseases. So central retinal artery occlusions or total retinal detachment. So the lesions occurring here along the pathway on you'll get no site from the visual fields in the left eye. So that's left anopia, an opium meaning last loss of sight. If there was to be a lesion at the optic chiasm here, be you'll get this picture but here, which is called bitemporal Hemianopia. So that's loss of the temporal vision. Visual field in both eyes by temporal, both temporal visual fields. Hemianopia so loss of half the visual field being the temporal half and typically occurs as a result of the optic chiasm being compressed by a tumor, usually a pituitary adenoma or craniopharyngioma. If you get a lesion along the optic tracked over him. You'll get what's called a contralateral home homonymous hemianopia. So in this example, the lesions on the left contralateral meaning you'll get right homonymous hemianopia homeowners means the same half of the visual field. So whereas here meant by temporal, we're looking at two opposite half of the visual field being lost homonymous means the same half. So the nasal on the temporal in both eyes and so it is in your right eye. So hemianopia again, half the visual field is gone. Um, so, um, on a muscle field defects will affect the same side of the visual field in each eye. On that commonly attributed to strokes, tumor abscesses, uh, or in pathology affecting the visual pathways that are posterior to the optic chiasm hemianopia if half the vision is affected and you could also get what I've called quandranopia see over here, which will get into where quarter of the vision or the visual field is affected. So if there's a lesion over here at DE, this is actually only affecting the myelo. So the outer gray line, um, you'll get what's called right. Homonymous upper quadrant. No beer. So we know it's on the right because we get contralateral effects on. We know it's anonymous because we get it's posterior to the optic chiasm on the reason we know it's a napper quarters know Quadrantanopia is because it's the myelo. It's the one that passes through the temporal lobe on That's the superior ones. If we remember the acronym Pits, we will get parietal inferior to put temporal superior. So a lesion in the temporal lobe will give you a contralateral homonymous superior or upper quadrant anopia, as in this case here with D or a lesion in the price a low, we'll get you contralateral homonymous inferior lower or lower quadrant in O. P. A. You could also get what's called a scatomas, and that's just an area of absence or reduce vision surrounded by areas of normal vision. Um, so they tend to happen in macular degeneration. You'll get this off central scotoma here, so you can't really see too out that exact spot there. This is just normal, uh, or you could only see through that point there, and that's constricted visual fields that called macular sparing or tunnel vision on. That's usually due to glucoma or retina pigmentosa. Um, if we move on now to the ocular motor trochlear and abuse and sniffs, and after that, we'll take a break. So briefly inspect the eyelids for any evidence of Tosis. Tosis is sort of eyelid drooping on that usually will indicate ocular motor nerve pathology, but it's also one of the triad of hornets syndrome. On it could also indicate any new a muscular pathology such of my senior process, and what you want to do is you want to move your finger. Or it happened, just something that's easy to focus on in the various axis of it of the eye movement in a hate pattern. So the heat pattern will cover all directions that the I should move roughly so again, approximately put 30 centimeters from a patient's face. Ask them not to move their head on just to focus with their eyes, and they're okay to move their eyes just to focus on the tip of your finger on, Then move it and hate so on. Just ask the patient to notify if they have any double vision or any pain. It's also important to observe for nystagmus, so in a stagnant is a vision condition in which the eye or just make repetitive, uncontrolled movements. So if you imagine this is the eye when it's trying to move one way and it can't, it will sort of start making these rapid movements like that. So it's also Trump would remember that the ocular motor never mainly main know for eye movement, but also the trochlea and abuse and snows there involved. But the ocular motility also innovates the left to Palpa, very superiorize. So that's what would cause your Tosis. That's what's in charge of keeping island open on it. Also innovates the sphincter pupil I muscle, as we saw with the pupillary, reflects the celeries fingers on day. This is what affects my OSIs of people a constriction or my dry assists, which is people dilation. So if you ever look at these sort of brief, very simplified diagrams of eye movement, so if we look at this one here, this shows you your right and your left eye on it will show you It's just so I've got s are short for superior oblique. Uh, sorry for superior rectus l r for lateral rectus. I offer in for your rectus I owe for in fear Oblique MRI for media rectus on S O for superior oblique. And this will show you the direction in which these muscles will pull the eye on. This is just a lot more schematic. An atomical diagram of how they sit there in the body. This image here shows a lateral view of the right eye. If anyone's wondered. So I've put the primary action of the muscle in bold on, then the other sort of second reactions aren't in bold, so superior Actis That's your main elevator of the eye. But it's also involved in adduction so away from the midline on media rotation. Inferior rectus is mainly involved in depression of the eye. But it also is involved in adoption A z well, so out from the way from the midline and lateral rotation. And then you have medial rectus, which is involved in, um, it might be a bit of in adduction a deduction. So again, towards the midline, I think here I meant away abduction away from midline. Um, I'll correct that. And when I send you these slides goes on, Do you get superior oblique, which is the main one for your lateral rectus so that ab ductions away from the midline on. Then you get inferior oblique. That's involved mainly in elevation and abduction and lateral rotation on superior oblique depression, abduction and media rotation of the eye. So the way to remember what's innovated by what is LR six s o for a oh three. So clean your nerve six will innovate lateral reclast. So elastics cranial nerves four innovate superior oblique on crayon S. O. S or four and then all the others are innovated by cranial nerves. Three. So a 03. Yeah. So if we look at what happens in pathology of the ocular motor nerve, you'll get Tosis due to impaired invasion of Levitra palpable superiors and you get the down and out people. So this is the classic sign of ocular motor nerve pathology. People's looking down on up. And that's due to the unopposed action of lateral rectus and superior oblique. Since they're the only muscles that are working because they're innovated by trochlear and of juice and sniffs on, the patient will often present to you with double vision. So the third nerve palsy causes Tosis on down and out or inferior lateral pupil. Um, patients will generally come in with double vision on Do you can get what's called a surgical or a medical third nerve palsy. In a surgical figment policy, there is pupil Involvement on this is because the parasympathetic, or constrictive fibers that constrict the people run on the outside of the nose. So when there's external compression, this impairs the function of these fibers on it causes pupil dilation or my dry Asus on. That's due to loss of function of the power, sympathetic innovation to the sphincter pubertally I. So the effects are emcee lateral. So with the the rights oculomotor nerve is impaired, the effect will be on your right eye on in the surgical fitness in the medical third nerve palsy there is not usually any pupil involvement. A surgical food move. Palsy. There will be pupils, dilation or people involvement because it's usually due to a next renal compression, compressing on that parasympathetic fiber that runs on the outside of the notes. So just a good thing. A tip to remember if there's Tosis, so drooping eyelid on a dilated pupil that's usually a surgical third nerve palsy. But if the pupil isn't normal, it's constricted. So Tosis and a constricted people or you're missing. There is an hydrosome. You've got Horner's syndrome, so that's quite a common one that might come up to trick you. So again, so poorly drawn diagrams there on my side. But this is mentally so. That's the pure normal. People know people involvement here. We've got the dilated pupil in the surgical. Certainly palsy. The most common cause is a posterior communicating artery aneurysm. Other causes will include cabinet Sinus lesions. These could be infections from both cysts or any tumors on surgical easings. Refer to compressive lesions, usually when it's the medical lesions. These tend to affect the central nervous fibers earlier than the peripheral ones, and these are non compressive. So these are things such as multiple sclerosis or vascular causes, such as diabetes on vasculitis. So it's important to remember if you have a food nerve palsy so Tosis and down and up presentation with an enlarged or dilated pupil. There's a surgical cause on that requires an urgent brain imaging. Usually a CT had to rule out any bleeds or aneurysms because they're quite common causes of compression, usually the posterior communicating artery, Others moving on to a truck. You know, the pathology Creon evident before. So cranial nerves 34 and six are tested together because they mainly control I movement. You'll get four sniffles artery because 1/4 of this policy sorry refers to paralysis of the truck you live on that controls your superior oblique. So s 04. The function of this muscle is to pull the eye to look down on in wits. So patients will tend usually present with double vision worse in the vertical plane. And we call this vertical diplopia diplopia meaning double vision and the rest the eyes going to sort of turn upwards on outwards on day shift off often sort of tilt their head to the contralateral or the unaffected site on compensate for the lack of interest in in the affected eye. The main causes of this policy are usually trauma or diabetes. Um, and the one way to remember it is can't see the floor with cranial nerve four damage on, but it's usually because patients will classically notice it when they're reading books. Or going down the stairs usually is well because arrest their eyes turned upwards and outwards, So moving onto the adduce and snow pathology arrest So passive the addition of a boost instead of controls lateral rectus LR six on the function of this muscle is to abduct the I horizontally away from the midline on the 640 will result in abduction of the eye by the media rectus muscle on that will give you a conversion Squint a scene But there patients will typically present with horizontal diplopia This time on is usually worse when they try and look towards the affected side on again causes here, usually diabetic neuropathy, stroke or infection controller. So in this picture here, is there the right create a cranial nerve. Six palsy on the woman's trying to look towards the right, but the latter actors muscle isn't working to pull this I towards the right. Um so a few questions for you guys to answer in the chapped. Let me know what's going on in this first picture by here. What direction is going on there All pauses that we've just covered. So hopefully you guys should get it. I'll have a look at the chart there. Can any of you tell me which I is the pathology is in a swell. A lot of you're getting it right. So this picture here perfect. So a lot of you've already said it. It's a right fourth new for the whole. See, I've given you the second one there by accident. But if you didn't see it pop in the chart what you think the second one is and again, which I You think it's in a swell? Perfect. So, yes, it's a left third nerve palsy on. You can't really see the pupil in the picture to tell whether it's surgical medical. But yep, that's perfect on again. I've given it to you. It's a in the last picture there for the takes. Time is a left sixth nerve palsy. So the patients trying to look to the left but the left lateral left lateral rectus muscle isn't working and they're not able to look towards the left with the left. So to remember them. Third nerve palsy. So you'll get ptosis that down on, uh, people on if it's surgical people violation vertical diplopia and 1/4 nerve palsy on the I will be up in upwards at rest on horizontal diplopia and a six nerve palsy on you. Get medial deviation. It rest. The last thing I'm gonna cover before we take a quick break is something called Internuclear Ophthalmoplegia. Um, this is a cause of horizontal conjugate. So not paired I movement. There's something called the medial longitudinal fasciculus on that coordinates both ice to move in the same horizontal direction by into connecting the third, the fourth and the sixth cranial nerve nuclear. What happens is if there's a lesion in the medial longitudinal fasciculus the MLF you get. It's a lateral adduction failure and the stagnant of the abducting eye on the opposite side. And it's commonly caused by multiple sclerosis or vascular disease, very common in multiple sclerosis, because the MLF is highly myelinated and there's a quick diagram that sort of explain what's going on. So here we have cranial nerves. Three nuclear hit, the midbrain cranial live six nuclear in the ponds on the MLF connecting them. In this picture, we've got a lesion in the right MLF, so the left eye is able to abduct to the left via the left cranial nerve, six lot or rectus muscle, but the right I cannot adducts towards the midline to the left as there is no communication, no communication to the right cranial nerve, three nucleus to innovate. Media rectus. So what you'll get is, um So the way of remembering it was I n o. So it's a lateral on its own adduction failure in the stagnants of the abducting any opposite side so into nuclear exam a pleasure i n o gets absolutely addiction failure. So since here the reasons on the left on the right Sorry, you're going to get addiction failure in the right eye on and the stagnant in the opposite I tries to abduct. So is the left eye is trying to abduct on the right eye is not doing anything. You're going to get this in a stagnant. So it's off a rapid division, that story rapid eye movement that you might notice when testing it so contact get base will be affected when trying to look left. However, when you're trying to look right, it won't be affected because there's no reason there's no lesion over here on the right eye in isolation should work. Okay, is what is the problem in the conjugate or communication between cranial nerves. Three and cranial nerve. Six. So, in the right sided inter nuclear ophthalmoplegia there is in pet adoption of the right eye with horizontal nystagmus of the abducting left eye on voluntary left case. Let's take the quick five minute break for you guys to, So stretch your legs. Get a cup of tea. Um, Onda, come back in about five minutes, if that's okay, serve your hopefully back on. We'll start off straightaway with some spot diagnosis about what we've already done and see if you guys are getting it. Okay, So a 35 year old female presents with a three months history of double vision. On examination, the right eye fails to adopt on the left eye, develops course and stagnants in abduction. If anyone can give me what the pathology is on which I it's in a swell m s can be the leading cause of it. Yes, but the specific name. So yet, ah, lot of you're getting it. That's great to see. So it is internuclear example Poesia of the right eye. So it's a lateral reduction failure. So since it's the right eye that's failing to a duct, we know that the lesions on the right on d Then we have and no nystagmus off the opposite eye as it tries to abduct um, knish. If you wouldn't mind after this. What diagnosis? Covering what you said before there was that month I missed after this. What diagnosis? Would you be okay to briefly cover what you just mentioned before on the brake? I think people are asking about the prosecutable. Yes, the process. Eso a 62 year old man is admitted with severe headache, nausea, a recent epileptic fit. He is noted to have diplopia when us to look laterally asking into look outwards. And you don't need to tell me which I is this one because I haven't specified perfect green, you know, six pathology, a problem with the of decent snow. So a 50 year old female admitted with weakness and visual disturbance on exam. In a tid examination, she's noted to have my dry cyst diminished direct right response to light shone into the affected eye on the consensual response in the affected eye is preserved. Any idea what's going on here? So her people is dilated on. She has a diminished response to light. When Sean in the affected eye. And that's diminished. Direct response. The consensual responses in the affected I still preserved. So this is optic on optic nerve pathology. Um, so the reason it's an optic nerve pathology is the direct response test. Is your Afrin on your affair into limbs in the consensual one test your e for So if the consensual responses okay, that means that the problems of the Afrin limb So that's your optic nerve on a 66 year old female presents with drooping left eyelid on day small left pupil. Her left eye also appears to have sunken on. She has a 30 year pack year smoking history. Yes, I like I love you have gotten the trap. There it is, horniness. It wasn't one of the things I've covered. Just remember that usually when there's pupil constriction and Tosis, you might very likely have Horner's syndrome and the pack your history in this indicating that she might have a pankos tumor. Very loose link. But I'm glad you guys noticed it. Um, Nissho, you okay to cover the prostitute people. Very cookie for a few hours. Yeah, eh. So when you talk about the prostitute people's, they're talking about the Argo Robertson people so classically seen in patients with neurosyphilis. So newer syphilis is pretty right these days. Okay, You don't really see many patients with surgery. Syphilis get with neurological involvement. But in patients who do have it some patients and get a lesions affecting the midbrain on da, uh, patients will get bilateral my OSIs. But the key thing is, in terms of the examination finding is that the people's they won't they won't construct with light. Okay, they don't They're not reacted to might, but they're still reacted to accommodations or they'll constrict with accommodate with the accommodation reflux and the way people remember. That's it. Because you think of it as prostitutes because you basically say the people can they accommodates but it But they don't react. Okay, because that's basically what happens in an argon Robertson people, because basically, with neurosyphilis the damage typically effects be fibers that affect the people who were effects. It doesn't actually affect the, uh, the accommodation reflex. Pop it and they help out. Thank you. Um, so so far, we felt with two sensory nerves on Day three motives, the trigeminal nerve is the first one that we're going to counter that involves both sensory and motor components. So to start off with the sensory component, there's three divisions of the trigeminal live. Um, there was meant to be a slight, actually sort of splitting up the face. Um, but apologies. It seems to have gone missing. So what you want to do is you want to assess this the three divisions of the face with a trigeminal nerve. I'll try and get the picture up before our necks. So a little break. Um, and you want to assess these three divisions with wool? He's a whisper, got more, And then so of the resources of spit on whether you should use a neuro tip or not, new tips can be a bit stop a bit to shop for the face, maybe, but just sort of check on what your local guidelines are. So what you want to do explain the modalities of sensation you're going to assess. So these are the light, touch and pinprick to the patient by demonstrating it on their sternum. First of all, on then, to assess the three different divisions, I recommend you assess the forehead, the cheek, and then the lower jaw, but sort of avoid the angle of the mandible itself. So around the lower jaw over there and you can't really go wrong. So forehead, so upper cheek for there and then the lower jaw. Ask the patient to close their eyes while you're doing this on, say yes when they can feel the touch on. If it feels the same on both sides on that assesses your sensory aspect of the nerve, then for the motor aspect of the liver, which is mainly your V three. Um, So because the trigeminal nerve creatinine of five has three divisions, it's the one the upset stomach on V two and the three, um So V three assesses the muscle of mastication for wasting eso. Just have a look. If there's any obvious wasting, ask the patient to clench their draw and palpate mass it. Er, so. The muscles of mastication are temporal. It's master in the pterygoid, and then you can ask the patient to open their mouth with resistance underneath to assess that the lateral pterygoid muscles on. If there's any deviation, it will be towards the side of any lesions, and that's usually due to unopposed action from the opposite terrible muscle, the cornea reflex that's V one. So use a wisp of cotton wall. Gently touch the edge of the cornea using a wisp. Of course, normal in healthy individuals, you should observe both direct and consensual. Blinking on the absence of a bringing response suggests pathology involving either the trigeminal nerve, which is the Afrin slim of this reflects, or the facial nerve, which is the E fair and the effect of limb of this, However in and ask e you don't actually do the cost of the cornea reflex just because it's a bit to tricky to do on. You don't really want a upset. Someone's I. Same thing for the George. Agree, flexed on. That's when you will use a It's a stretch reflex, and it was a slight jerking of the draw upwards in response to a downward tap. So what you want to do is ask the patient. Open the mouth facial finger horizontally across the patients, 10 on with the tendon hama. Tap your finger gently in sort of a downwards motion, and you should get some slight drinking of the draw upwards in a healthy individual. But in patients usually with the upper motor neuron lesions, the drawer might briskly move upwards, closing the mouth too close completely. So what you want to do is that you want their joints or close a little bit, but not completely. But again, the Georgia reflex on the corneal reflexes you don't really do in a cranial nerves examination and actually ski. But you might be asked to stop. Just explained them briefly on both the Afrin and Effort pathways of the Drops Jeffrey Georgia Reflex RV three of the trigeminal live. But in the cornea reflex, only the Afrin is trigeminal. The front of the effect of it is the facial nerve. So, um, in terms of pathology, you might get trigeminal neuropathy, so that's altered. Sensation could be idiopathic or bells. Palsy equivalent. Cavernous Sinus syndrome, cerebellopontine angle, acoustic neuroma, Most chronic meningitis. You could have inflammatory problems. You could also get them trigeminal neuralgia, which is pain, and you'll have severe Um, your actual facial pain gets so brief electric shock like pains on pain that's evoked by light touches or when the patients or shaving or Washington or brushing their teeth on for trigeminal neuralgia you can treat this with carbamazepine or surgical decompression. Ast far as late as guidance, just moving onto the facial nerve. So we've skipped the abuses because we've done that with the ice. So cranial nerve. Seven. The fit supplies Full main things. You don't remember them. Face here. Taste in tier. So face here, taste in tier the muscles of facial expression on your face. Here is the nerve to strip. EDS. Paralysis of this video muscle can resort in hyper accuses on that sort of reduced tolerance to any loud sounds. Taste. So the anterior two thirds of the tongue, the special sensation of taste is by the facial nerve and then tear because the parasympathetic fibers run to the back room or bands so as the patient, if they've noticed any changes in their taste, that was probably the easiest way to assess that aspect. Awesome. If they've noticed any changes in their hearing on, then look for signs of reduced facial tone, Um, so so of drooping of the mouth or anything, so that covers your sensory aspect of the facial nerve for the most raspy because it's going to use the muscles of facial expression you want. The patient to make some expressions feet Something to raise your eyebrows if you're. If you're surprised to assess frontal lists, tell them to scrunch up your eyes and don't let me open them. Tell them to blow out their cheeks on. Don't let me deflate them. Ask them to do a big smile for you last time to try and whistle. Too personal. It's a swell. So with facial nurse palsy is you can get upper and you can get lower motor neuron lesions in an upper motor neuron lesion. The lighter green lesion over here in the upper motor neuron. You see, I only got just draw until just one side. Um, the upper motor neurons the affected side will be contralateral on it will involve the lower muscles of facial expression on the forehead is sped. Now the reason for head this pet is that you can see it's getting innovation from the other upper motor neuron over here. So that's why you'll get forehead sparing in the upper motor neuron lesions. But in lower motor neurologic, the effects will be upset lateral on the same side. So this lesion here, it'll affect upper on blower muscles of facial expression so the forehead isn't spared. It is affected on. You might also get some incomplete closure, hyper accuses and lost of taste the anterior term. So the forehead in upper margin your only gyn will be spared to do to the bilateral innovation, and it will be on the contralateral side that you'll see the effect. So although this nerve here is no longer working, this nervous compensating on the forehead is bed. The main cause of an upper motor neuron lesion is usually a stroke and then lower moving your lesions. You get Bell's palsy, which will cover Ramsey Hunt syndrome, which is usually due to herpes zoster. Um, it's it's not herpes Austria Opticus, and it's caused by a reactivation of the ValuJet varicella zoster virus in the genetic gene. Congenital. It's a ganglion of the seventh cranial nerve, so that's Ramsay Hunt syndrome. On you Get acoustic neuromas brought a tumor's hatred of the multiple Sclerosis on diabetes could also cause lower motor neuron lesion. Each of these in their own. The right is a disease or pathology that you can look into for ages. So I commend doing a bit of reading about each one, but I'll cover just this one over here. So can anybody tell me what's going on in the picture? It's the clue is in the copyright, Lincoln the bottom. But if you could tell me also which side it's on, that would be great. Yeah, any idea is what's in the picture. Yeah, so, yes, Bell's palsy is a low, most new religion on. Yes, it is affecting the left side here. So Bell's palsy. It's an Indian pathic syndrome, affecting the facial nerve. The etiology isn't completely known, but there has been thoughts in the past that maybe the herpes simplex virus is involved, but they're not too sure on that peak incidence. You'll get in around people age 20 to 40 years old. On it's quite more common in pregnant women. You'll have a cute but not sudden onset unilateral lower motor neuron facial weakness, sparing just the extra ocular muscles and muscles of mastication on. Patients may also notice the post auricular pain. Um, on day could have altered taste again because we know the facial nerve supplies taste to interior two thirds of the town. They could also get dry eyes because it supplies your tear glands on hyper accuses again because the facial nerve is important for the movement of stuff. PDS, um so for in terms of management, usually it's or a prednisolone, the use of a psych clavier isn't really recommended in all sources, but because Ramsay Hunt syndrome can present quite similarly, some local guidelines recommend using acyclovir because then that will cover the management of Bell's palsy and Ramsey Hunt syndrome. Most people make a full recovery within 3 to 4 months on if untreated, around 15% of the patients will have permanent to moderate severe week to moderate to severe weakness. Moving on to the eighth train on over almost there that vestibular quickly enough what you're going to want. This nerve covers hearing and balance so assessment of those things. So the first thing you just want to assess the crude hearing so position yourself approximately 60 centimeters from the patient's here on cover their other year, usually best if you cover it for them. But make sure that they're okay with that and say three numbers and ask the patient to repeat them back to you. Start off just whispering them if they hear that and they can repeat them back to you. That's great. Move on. But if they can't move up to conversational volume, then speak of it loudly and, if necessary, just move into 15 centimeters. Ask the patients too much. Then, for the vestibular aspect of the nerve there balance. What you want to do is ask him, stand up on March on the spot with their arms outstretched and their eyes closed. Normal result. The patient's going to stay in the same position. If there's a vestibular region, you'll find that the patient starts turning towards the side of the lesion. Just make sure you're sort of around the patient to catch them if they lose consciousness and fall or get dizzy or anything like that. So then so properly? Assess Hearing of the patient you want to do. Run a PSA test on Weathers. Test. So with Renee Test Place a vibrating tuning fork, so not the tuning fork on something first. Usually your fingers. It doesn't have to be too loud on. Then place it with the end on the mastoid process on. Tell the patient to tell you for Ask them rather to tell you when they can no longer here it when the patient no longer here is the sound. You can remove the tuning fork in front of the external, the tree mediators, So just hold it to about. But they're anything can hear the sound that means a conduction is lot of them bone conduction. Um, it's harder. Some sources recommend that you do the mastoid process and then tell them to tell you when it they can stop hearing it on, then repeat it again. Let's stop the vibration and saw the vibration again on Hold it out Externally, it gets a bit messy, and you can't truly tell which is louder. But the theory is that once their bone conduction, they can no longer here it on bone conduction on the mastoid process. If you then move it to a conduction and they can still hear it, that means the air condition is louder. Uh, that's a positive result. If they're conduction is louder, and that means they've either got normal hearing all. They have sensory neuro hearing loss if it's negative. So once you've moved it from bone conduction on, put it for a conduction, they still can't hear it that probably means that bone conduction was louder on on. That means they have conductive hearing loss with weapons test, strike the tuning fork again and placed it this time. Place the foot on the midline and ask the patient where they hear the tone loudest. So they might say it's centrally, oh, towards the left or towards the right ear. If it's good equally in both, yes, that's when they'll tell you that it's central on. That's usually symmetrical hearing on that could either be symmetrical hearing as a normal hearing or symmetrical hearing loss. If it's a symmetrical yeah sensory neuro hearing loss, they'll tell you that they can hear the sound in the unaffected side, so sound is heard louder on the side of the intact it here. If it's conductive hearing loss in a PSA and it's a symmetrical, they will tell you that they can hear the sound louder in the affected site. That's because it's going by a bone conduction to the affected side, so let's say they have conductive hearing loss in the left. If you put it on, it's a symmetrical. If we ignore Central for now on, they tell you it's louder in the left. That means they've either got here sensor in your sensory neuro hearing loss of the right ear, and it's localized the unaffected side. Or they have conductive hearing loss off the left ear. And it's localized to be effective side because then the bone conduction is working in their favor on your S P Strike out initials video. It's great with his videos are. So I definitely recommend going to do that. And here's just a quick diagram explaining that so start off with the next test. If they're conduction, is lot of the bone, it's positive they've either got normal hearing or sensory neuro hearing loss, then move onto ever's. If it's sent, they have normal hearing, or they've got symmetrical sensory neuro hearing loss. If it's hurt, if it's a symmetrical, it'll be heard in the unaffected here on, then vice versa. If bone conduction is louder, inr in a move on, they've got conductive loss somewhere. Move onto Webber's. If it's Central, they might have symmetrical convert conductive loss, but that's really rare and highly unlikely. More likely, that's going to be asymmetrical on its heard in the affected yet, So let's work through some examples just to see if you guys are okay with that. If the Renee test is positive, result in both ears on Weathers is central. What are the options of what could be going on there? Any guesses, guys don't more if it's if you want to show exactly it's in the normal or there's bilateral sensorineural hearing loss, it's hard to differentiate exactly which one, but you can narrow it down to those two Renee positive result in the right here. Negative results in the left ear, so bone conduction was louder in the last year on Webber's has localized the left ear. What are the options of what could be going on there again? Answer in the chart price. So yet you're getting it great guys. Well done. So the positive result in the right ear means that it's either normal or sensory neuro in the right here on. But because the weather's has localized the left ear, that means it's either censoring your it's either sensorineural in their idea or left conductive hearing loss because we have the negative results in the left ear. It could also be the left conductive hearing loss on then the final example, you guys just quickly do in the chat. So Renee positive result in the left ear. This time, negative result in the right here on Weathers has localized to the right here. Yeah, it's not a trick question. It's just a reverse of what was before. So just quick causes of conductive hearing loss. This usually occurs when is unable to effectively transfer at any point between the outer area, external auditory canal tympanic membrane or the middle of the ossicle. They're usually a younger age of onset of your issues. An external or middle ear on noisy environments tend to improve. Hearing on the sun would be distorted in sensory neuro hearing loss. It's usually due to dysfunction of the cochlear or the vestibular. Cocky a nerve. So that's where we're assessing it. Here, you more patients will tend to be a middle or elderly A. A. Job onset noisy environments will worsen it. Hearing in this case, um, and they will lose the higher frequencies as well. With time on, they could often present with tinnitus, which you saw this annoying ringing sound in your ear to so just a summary of sensorineural and conductive hearing loss that so dysfunction of the calculator or the vestibular cochlea, never just increasing age. Excessive noise exposure, genetic mutations, some viruses and ototoxic patients call sensory neuro hearing loss. Conductive hearing loss tends to be excessively a lapse or titers. External otitis media prefer to tympanic membrane or for sclerosis, so the closer, pharyngeal and vagus nerves are assessed together because they're closely related in terms of their functions. So the loss of fire engine of gives motor function to this island for MDS muscle, and that's used in elevation of the pharynx during swallowing. And speech on the glossopharyngeal nerve also conveys the special sensory information that is taste from the posterior third of the tongue. So the facial never did the anterior two thirds. It's, um, to go so far and deal for this for the poorest eeriest good. The vagus nerve doesn't motor information to several muscles of the mouth, which are involved in the production of speech. Other than it's many parasympathetic functions that we know are in the floor, it's and abdomen. So the easiest way to assess this in a Noski is ask the patients if they experience any issues with their swallowing or if they've noticed any changes to their voice or a cough, you could ask them to take a sip of water and observe the patient swallow. And if they're sort of any infection in the swallow, so that could be that the cough halfway through. Oh, there's a change change of quality in their voice that could be due to closer for in jail, the Afrin slim or vagus nerve Lee, if errantly, um pathology, um, you could also inspect for palate symmetry. So ask your patient, open up wide and say, Ah, rather, parents should elevates symmetrically on the uvula should remain central. However, if that doesn't happen, a cranial nerve 10 vagus nerve lesion will cause a PSA Metro cool palate elevation on the uvula. We'll deviate away from the lesion so the villa deviates away from lesion. You could also do the gag reflex, but don't actually do this in a mosque. You could just mention that you could test it. It's unlikely that you will do this in an actual ski cranial nerve. Nine Lot of fragile meant mediates the Afrin Slim on Creon of 10. The vagus will mediate the E fair in theater single um, of the gag reflex stuff. Polla gee, common to both nerves. You might see speech problems swallowing issues or breathing problems with people that have just glossopharyngeal palsy on its own. They might even be asymptomatic. Um, and then with vagus nerve pathology, you might also get hoarseness of voice. Some disk me on some tachycardia due to the wider, sympathetic effects that parasympathetic effects of the last two nerves to go the accessory nerve inspect for evidence of sternal cleidomastoideus trapezius muscle wasting. So these are the muscles that controls. Then you want to ask the patients to raise their shoulders with and without, and then with the resistance using trapezius, um on. Then ask the patient to turn their head to the left under the right on with Tums of against resistance just sort of put the dorsum of your hand gently and apply some resistance. But don't make it look like you're stopping the patient across the face, because that won't go too unto well, So the left sternal cleidomastoideus contracts it in head to the right on vice versa. So when you get pathology, any accessory nerve palsy, you might get shoulder droop on the it's a lateral, the same side of the weakness. Or you might get weakness turning the head to the contralateral side of the religion. And that's because the left side, um asteroid contracts to turn to the right. Onda right sternocleidomastoid contracted turn to the left. So weakness turning to the head is contralateral to the side they turned to is contralateral to the side of the lesion. Onda hum ultimate slide. Can anybody tell me what's going on here? On what side It's on? Yeah, the usual. Oh, move away from the lesion. Yeah. Okay, Now it's just in response to a question. So yes, wasting of the tongue. Yeah, well done. It's come through and it's left hypoglossal nerve injury. So the hypoglossal never. We've said that this is involved in the function in in falls in the function of tongue movement. So what you want to do you is you want to ask the patient to stick their tongue up, inspect it for obvious, wasting off the circulation's, Then ask them to protruding tongue. Um or you notice is that the tongue will deviated towards the side of lesion on. That's because there's overactive of the functioning January losses muscle on the unaffected side of the tongue, so its own. We'll deviate towards the lesion on the way to remember that is like your wounds. So some of you if you trip and fall and get a cut. My have used to lick it. No judgment here that will help you to remember that the tongue deviates towards towards the side of the lesion. Then finally, to test the tongue is a muscle. You have to test it against resistance, place your finger on the cheek and ask them to push their tongue against it and just feel for resistance on. You'll get weakness on the side of the lesion as well. So the final spot diagnosis it works on. We've given you the first one. A 52 year old man attends the emergency department with one day history of left sided facial paralysis on Otalgia. Um, neurological assessment identifies. The paralysis includes the left side of the forehead. Any ideas what it is? Yeah, So, yeah, it is Ramsey Hunt Well done on upper motor neuron lesion would be forehead sparing, So this includes the forehead, so we know it's a lower motor neuron lesion. and I'd be happy with that. To be honest, the the reason it's not on a Q stick. Neuroma is the patient would have a more gradual onset of symptoms, and it would probably include vertigo on hearing loss. So it's really any lower margin. Your religion is sort of along the line, but, um, Z Hunt was what the question was getting out. A 45 year old male presents to the emergency department with a sudden onset horizontal diplopia. It started about two hours ago and isn't associated with any headache, fever or nausea. He has a past medical history of hypertension, poorly controlled diabetes on some of the stroke two years ago. Any ideas what it is here? This could be anything from the entire presentation, by the way. Well, then it's a six nerve positing on 18 year old female who has been stabbed in the neck, is found to have an inability to contract the sooner clogged your mastoid on upper fibers of trapezius on that side. What nerve is affected here? Yeah, won't insult any of the intelligence it will build on guys. Accessory nerve. Last one, a 70 year old female presents following trauma to the head. And she reports not being able to smell asthma was before the trauma. An issue of smell in your nerve One. Yet so again, head trauma can cause sharing of those nerve fibers. A quick summary of some of the important things. The reflexes, the corneal reflex. The Afrin Effecter is V one Europe, same division of the trigeminal nerve. Your effort, your effecter, is the facial new bilateral eyes. It's the temporal brand, but branch off the facial nerve. But facial nerves enough. The way I remember Afrin and the Farrant Afrin is after. Okay, I feel that it's not great. Um, e Farrant is the effect. Er, the cough reflex. Both limbs are cranial nerve. 10. The got reflex. The Afrin feeling is creation of nine and the effective cranial nerve 10 on the Georgia. Both limbs are the three. Your examination were wrapping up here. Find the patient on wash your hands, summarize your findings. Offer to perform the reflexes we talked about. If you haven't already to mention them, the specific nerve to complete your examination see, you want to do for endoscopy or Salmasi Go pee. You could mention that earlier on when you're doing the eye offer to perform otoscope be and in your imaging you think is relevant. A formal hearing assessment and finally, tell the examining you want to them. Do a full upper and lower limb neurological examination. Uh, okay, I feel that the A is meant to be, um, are for a fair in, but it's not really the best new Monica. Remember eso final run through what you have to do? The nose. Inspect the nostrils. Asked him about the sense of smell the eyes. Make sure you've inspected the pupils. Visual acuity, color vision, pupil reflexes with your pen torch. Visual neglect on your visual field with you inkling fingers. Do they hate test for the ocular motor mortality? And that's gonna assess cream on there three and four and six. Unlawful to do a some muscular Be when you get to the patient's face, check for sensation in the three divisions of the trigeminal nerve. Check the muscles investigation. Offer the corneal Georgia reflexes on check the muscles of facial expression in the years you want to check their hearing, they're gross hearing, so I have any changes of a net and do Renee my best tests and assess that the stimulus system. See with the balance in the mouth after about any issues with swallowing, get into coffee, look for polyps, symmetry the position of the uvula in the tongue on offer to do a gag reflex. And then finally, the neck and back inspect muscles, shoulder rays on him turn right and left with resistance. And these are just some final top tips for your examination is a bit on fundoscopy of the electric, but you guys can read that in your old untime. A rapid over there. Let's see. Thank you.