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38 - Focal neurological examination

from Section 9 - Neurosurgery

Published online by Cambridge University Press:  05 July 2015

By
Harry Bulstrode ,
Yezen Sheena  and
Diederik O. Bulters
Edited by
Petrut Gogalniceanu ,
James Pegrum  and
William Lynn
Harry Bulstrode
Affiliation:
University College London
Yezen Sheena
Affiliation:
Plastic Surgery, Health Education East of England, Cambridge, UK
Diederik O. Bulters
Affiliation:
Honorary Senior Clinical Lecturer, Wessex Neurological Centre, Southampton, UK
Petrut Gogalniceanu
Affiliation:
Specialist Registrar, General and Vascular Surgery, London Deanery
James Pegrum
Affiliation:
Orthopaedic Registrar, Oxford Deanery
William Lynn
Affiliation:
Specialist Registrar, General Surgery, North East Thames
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Summary

Neurological examination is traditionally divided into examination of the cranial nerves and examination of the peripheral nervous system. In fact the two routines are complementary, and serve a common primary goal: to localise pathology within the nervous system, central and peripheral. Together with an impression of the type of lesion, derived primarily from the history, this localising information is central to correct interpretation of subsequent cross-sectional imaging.

Examination of the cranial nerves

You may need to select appropriate components of the following examination routines according to the clinical scenarios and guidance provided by examiners. This is a test of frontal lobe function.

Checklist

CN I (olfactory nerve)

• Not routinely tested

CN II (optic nerve)

• Acuity: each eye individually

• Fields: four quadrants to confrontation

• Reflexes: accommodation; direct and consensual light reflex

• Ophthalmoscopy: visualise the disc, exclude papilloedema

CN III, CN IV, CN VI (oculomotor, trochlear, abducens nerves)

• Ask patient to report any double vision during testing.

• Instruct patient to keep the head still.

• Ask patient to follow finger with eyes and report any double vision.

• Move finger to all extremes of gaze in an H-shape, to confirm normal upgaze/downgaze in both eyes, in abduction and adduction.

CN V (trigeminal nerve)

• Assess fine touch sensation in the three divisions:

• ophthalmic (Va) over temple

• maxillary (Vb) over cheek

• mandibular (Vc) over angle of mandible

• Confirm masseter/temporalis contraction on clenching teeth.

• Elicit corneal reflex and jaw jerk.

CN VII (facial nerve)

• Ask patient to:

• raise eyebrows

• close eyes tightly

• puff out cheeks

• show teeth

CN VIII (vestibulocochlear nerve)

• Test recognition of whispered speech in each ear individually.

• Weber's and Rinne's tests.

CN IX (glossopharyngeal nerve)

• Offer to test gag reflex.

• Prompt the patient to cough, looking for a strong cough.

• Prompt the patient to swallow, observing for symmetry.

Type
Chapter
Information
Physical Examination for Surgeons
An Aid to the MRCS OSCE
 , pp. 332 - 352
Publisher: Cambridge University Press
Print publication year: 2015

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