ENT

See Also

 Rinne/Webber with left-ear deafness on Youtube.

Neuro Exam

Glasgow Coma Scale

Neuro exam could either be cranial nerve + pathological reflex exam, BPPV/Meniere's exam, or
leprosy exam. Each is quite different and requires a different anamnesis, physical exam,
prescription, and education.

BPPV or Meniere's

1. Introduction
2. Anamnesis
3. Informed consent
4. Wash hands
5. Vital signs
6. Romberg's test
7. Finger-to-nose test
8. Check some relevant cranial nerves
9. Check for nystagmus
10. Dix-Hallpike maneuver
11. Treat with Epley's maneuver. (In the past, medication was prescribed. It is not
recommended anymore.)
12. Educate the patient: if the patient feels nausea/dizziness when getting up from a laying
down position, ask the patient to get up sideways instead.
  Dix-Hallpike maneuver on Youtube.

Leprosy

Ulnar nerve palpation

Peripheral nerves palpation

Nerve enlargement in leprosy

 Leprosy is also known as Hansen's disease.

 Know the names of the nerves you're checking for enlargement.
 Be able to tell the difference between multibacillary (>5 lesions) and paucibacillary (<6
lesions) and their treatments, including which drugs need to be taken under supervision
(note: the WHO guidelines differ from standards of practice in the USA where rifampicin
is taken daily).
 After the exam, refer the patient to the lab. The patient needs to have AFB (acid-fast)
smear done using a sample from their skin lesion.

 Treatment of Leprosy on WHO.

Videos of Leprosy Exam

 Hand nerves on Youtube.

Cranial Nerve Exam

1. Olfactory nerve: Ask if the patient has noticed changes in the ability to smell.
2. Optic nerve: Use a Snellen chart and a flash-light to check pupillary reflexes in each eye.
 3. Oculomotor nerve: Draw an "H" in the air with your finger. Ask the patient to follow
with their eyes only. Check for double-vision.
4. Trochlear nerve: (Same as #3)
5. Trigeminal nerve:
o Sensory: Touch the jaw, cheek, and forehead with patient's eyes closed and check
for sensation. Do corneal reflex by touching cotton in eyes.
o Motor: Ask patient to clench teeth and feel masseter (sides of forehead) and
temporalis muscles (below ear-lobes). Ask patient to open mouth while you push
their chin up.
6. Abducent nerve: (Same as #3)
7. Facial nerve: Ask patient to puff cheeks, smile with teeth visible, and crease forehead (act
surprised).
8. Vestibulocochlear nerve: Perform Rinne and Weber tests.
9. Glossopharyngeal nerve: Ask patient to say "Aaaah!"
10. Vagus nerve: (Same as #9) Ensure uvula does not deviate.
11. Accessory nerve: With patient facing left, ask them to face right and resist by pushing on
their face in the opposite direction. Do for opposite side. Ask patient to lift shoulders (i.e.
shrug) while pushing down with your hands onto the patient's shoulders.
12. Hypoglossal nerve: Ask patient to stick tongue out. Check for deviation.

Pathological Reflexes Exam

The cases that may come up include a chief complaint of headache.

Youtube Videos of Pathological Reflexes

1. Romberg's test: Stand beside standing patient. Ask them to close eyes and watch for
sway.
2. Tandem gait test: Patient walks heel-to-toe and then with eyes closed without falling.
3. Hoffman's sign: Hold patient's hand and tap their middle-finger from above. Index finger
movement: positive.
4. Chaddock's sign: Stroke on lateral side of ankle. Positive: Babinski reflex. (UMN lesion)
5. Oppenheim's sign: Stroke anterior tibial region. Positive: Babinski reflex. (UMN lesion)
6. Gordon's sign: Squeeze calves. Positive: Babinski reflex. (UMN lesion)
7. Schaefer's sign: Squeeze achilles tendon. Positive: Babinski reflex. (UMN lesion)
8. Brudzinski's test: Patient supine. Flex neck. Positive: patient lifts legs up. (meningitis)
9. Kernig's test: Patient supine with knee and hip at 90° angles. Extend leg at knee. Positive:
pain. (meningitis)
10. Lasegue's straight-leg raise test: Patient supine. Lift leg holding the ankle with knee fully
extended. Positive: pain in sciatic nerve distribution.

Catheter (Foley) Insertion

This station requires students to know the indications, contraindications, and risks of
complications of catheterization before beginning, and also know the parts of the catheter and
what they are used for. Know the amount and type of liquid used to inflate the balloon. Don't
forget to test the balloon before installing the catheter. The doctor may ask further questions such
as: how often does the urine bag need to be changed? how long can we leave a patient
catheterized? can you catheterize a conscious patient?

See Also

 Catheter insertion procedure on University of Ottawa.

Posterior Eye Exam

Fundus of the eye

Foveal reflex
Labeled right eye fundus

Ophthalmoscope

Students will be expected to perform a short anamnesis, informed consent, actually using the
(direct) ophthalmoscope to inspect a patient's eyes, and then they'll be presented with a picture of
the fundus and asked to interpret it.

1. Anamnesis:
1. Determine if the patient wears glasses or contact lens; what number lens do they
wear? (Remember this number!) Also, ask the patient if they have diabetes
mellitus or hypertension. (Ask the patient if you need to perform a visual acuity
test - the doctor will say no).
2. Performing posterior eye exam:
1. Inform the patient that you'll be doing an eye exam using the ophthalmoscope. It
isn't painful and dangerous but you'll need to shine a light into their eyes and get
very close to their face. Get their consent and proceed.
2. Ensure the room is dark.
3. Ask the patient to remove their glasses. Set their lens number onto the
ophthalmoscope.
4. If the patient is wearing contact lens, you must leave the number on the
ophthalmoscope at zero. (not sure!)
 5. Hold the ophthalmoscope properly: like an ice-cream cone but with your index
finger vertical.
6. Left-left-left, right-right-right: inspect the patient's left eye, with your left eye,
using your left hand. Then, inspect the patient's right eye, with your right eye, and
right hand.
7. Ask the patient to look at something behind you in the distance the entire time.
8. Turn the ophthalmoscope on and start from about 30 cm away by trying to focus
the circle of light into their pupil.
9. At first, the image of the fundus visible through the ophthalmoscope will be
blurry, but eventually when you get very, very close to the patient (almost
touching), you will be able to see the blood vessels on the fundus.
10. If you can see some blood vessels, move slightly towards the patient's lateral side
while following the blood vessels to the optic disc.
11. Mention that you can see the optic disc, which appears like a bright full-moon in
the night-sky, where all the blood vessels converge. Also mention the macula, the
dark area.
12. The foveal reflex is hard to see but it appears as a tiny light in the middle of the
macula. It's not important to find this during the OSCE.
3. Interpretation:
1. After performing the eye exam, you'll be presented with a photograph that you
need to interpret:
2. Identify the optic disc (optic nerve head, aka. papil of the optic nerve), optic cup,
and macula.
3. Identify the veins and arteries: veins are thicker and darker than the arteries
(actually, the retinal arteries lack a muscular coat, so they are more correctly
called arterioles.) The diameter of the arteries is about 2/3 that of the veins.
4. Ensure you can identify a few common diseases such as glaucoma and diabetic
retinopathy just by looking at the photograph. The doctor may ask some questions
such as: what other exams are performed when glaucoma is suspected?

See Also

 Fundoscopic exam on Stanford Medicine.

 Indications for ophthalmoscopy on Wikipedia.

IV Line
This is a 15 minute station that can involve one of three scenarios: hemorrhagic shock, non-
hemorrhagic shock, or dehydration. The doctor may ask questions such as how often an IV line
needs to be reinstalled and if you must puncture more distally or proximally.

Hemorrhage class Blood loss Signs

1 0-15% ↑HR.
2 15-30% ↑HR, ↓BP, and ↑RR.
3 30-40% ↑HR, ↓BP, and ↑RR, oliguria.
4 >40% ↑HR, ↓BP, and ↑RR, anuria.

Differences between veins and arteries

1. Veins are superficial and thus, easier to access.

2. Veins have a more steady blood pressure.
3. Veins have thinner walls, so they're easy to penetrate.
4. Veins have a larger lumen.
5. Veins are less mobile than arteries.

Local terms
Plabott
a portmanteau of "plastic bottle". This is another name for the infusion bag.
Abbocath
Abbocath is the name of the company that produces the over-the-needle catheters that are
locally known by this name.
Grojok
when the stopper is released completely. So, instead of dripping, the infusion flows freely
down the tube.

Types of solutions given via IV

 Crystalloids: (cheap, semi-permeable)

1. Hypotonic: e.g. 5% dextrose in water (D5W).
2. Isotonic: Isotonic is usually the most commonly used solution, specifically, ringer
lactate. e.g. ringer lactate (RL) and 0.9 NaCl.
3. Hypertonic: 3%, 6% 7.5% normal saline.
 Colloids: (expensive, stay longer in the blood vessels)
1. Protein: e.g. serum albumin, gelatin.
2. Non-protein: e.g. starches, dextrins.
 Packed RBCs: usually frozen, so it needs to be warmed to 37C.

Usually, crystalloids are always given first no matter what. This is because packed RBCs require
some time to be warmed and the patient's blood-group to be assessed. Crystalloids will quickly
restore fluid into the body's tissues. Colloids may be given afterwards to keep the fluid volume
inside the vessels high if needed.

Indications

Fluid resuscitation for electrolyte balance or dehydration. Also, to give medications

intravenously.

Contraindications

1. IV line cannot be started in an area of the body where there is: edema, burns, injury,
recent surgery (e.g. mastectomy), phlebitis, or sclerosis (scar tissue).
2. Where ____ score is less than _.

Complications

Infection, air embolism, hemorrhage, hematoma, thrombophlebitis.

See Also

 Acute Stroke Algorithm - aka "Gadjah Mada Stroke Algorithm".

 Intravenous cannulation on OSCESkills.com.
Cranial Nerve Examination
There are 12 pairs of nerves that come from the brain, one for each side of the brain. One or
more of the nerves can be affected depending on what is the cause. Common conditions include
space occupying lesions (tumours or aneurysm), myasthenia gravis and multiple sclerosis,
although there are many more.

For a detailed list visit this site.

The cranial nerve examination involves a number of steps as you are testing all 12 of the nerves
in one station. Be certain to know which nerve is being tested next and what tests you must
perform for each specific nerve.

This guide will take you through each nerve systematically, but personal techniques may be
adopted for this station so that it flows best for you. It can seem like a daunting station as there
are many steps to it but hopefully this guide will help.

Subject steps
1. The following equipment is required for a cranial nerve examination:
o Handwash
o Item with distinct odour (e.g. orange/lemon peel, coffee, vinegar, etc)
o Cotton ball
o Pen torch
o Fundoscope
o Tuning fork
o Neurological reflex hammer
o Snellen charts
o Ishihara plates

o Cranial Nerve Examination equipment

 o Typical Snellen chart to estimate visual acuity

o Example of an Ishihara color test plate.

2. Wash your hands, introduce yourself to the patient and clarify their identity. Explain the
procedure and obtain consent.

o Wash your hands

3. The Olfactory nerve (CN I) is simply tested by offering something familiar for the
patient to smell and identify, for example orange/lemon peel, coffee, or vinegar.

o Test the olfactory nerve

4. The Optic nerve (CN II) is tested in five ways:
o Acuity
o Colour
o Fields
o Reflexes
o Fundoscopy
5. The acuity is easily tested with Snellen charts. If the patient normally wears glasses or
contact lenses, then this test should be assessed both with and without their vision aids.
 o Typical Snellen chart to estimate visual acuity
6. Colour vision is tested using Ishihara plates which identify patients who are colour blind.

o Example of an Ishihara color test plate.

7. Visual fields are tested by asking the patient to look directly at you whilst you wiggle
one of your fingers in each of the four quadrants. Ask the patient to identify which finger
is moving.

Visual inattention can be tested by moving both fingers at the same time and checking the
patient identifies this.

o Visual fields test in one pair of quadrants

o Visual fields test in the alternative pair of quadrants

8. Visual reflexes comprise direct and concentric reflexes.
 Place one hand vertically along the patients nose to block any light from entering the eye
which is not being tested. Shine a pen torch into one eye and check that the pupils on
both sides constrict. This should be tested on both sides.

o Shine a pen torch into the patient's eye

9. Finally fundoscopy should be performed on both eyes.

o Perform fundoscopy on both eyes

10. The Oculomotor nerve (CN III), Trochlear nerve (CN IV) and Abducent Nerve (CN
VI) are involved in movements of the eye.

Asking the patient to keep their head perfectly still directly in front of you, you should
draw two large joining H’s in front of them using your finger and ask them to follow your
finger with their eyes. It is important the patient does not move their head.

Always ask if the patient experiences any double vision, and if so, when is it worse?

o Get the patient to follow your finger

11. The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor
supply to the muscles of mastication. There are 3 sensory branches of the trigeminal
nerve: ophthalmic, maxillary and mandibular.

Initially test the sensory branches by lightly touching the face with a piece of cotton wool
followed by a blunt pin in three places on each side of the face:
 o around the jawline,
o on the cheek and,
o on the forehead.

The corneal reflex should also be examined as the sensory supply to the cornea is from
this nerve. Do this by lightly touching the cornea with the cotton wool. This should cause
the patient to shut their eyelids.

o Opthalmic

o Maxillary

o Mandibular

o Corneal reflex test

12. To test the motor supply, ask the patient to clench their teeth together, observing and
feeling the bulk of the masseter and temporalis muscles.

Ask the patient to then open their mouth against resistance.

 Finally perform the jaw jerk on the patient by placing your left index finger on their chin
and striking it with a tendon hammer. This should cause slight protrusion of the jaw.

o Muscles of the head and neck

o Feeling the masseter muscles

o Feeling the temporalis muscles

o The jaw jerk

13. As previously mentioned the Abducent nerve (CN VI) is tested in the same manner as
the oculomotor and trochlear nerves, again in eye movements.
14. The Facial nerve (CN VII) supplies motor branches to the muscles of facial expression.

This nerve is therefore tested by asking the patient to crease up their forehead (raise their
eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks
and reveal their teeth.
 o Crease up the forehead

o Keep eyes closed against resistance

o Puff out the cheeks

o Reveal the teeth

15. The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus
of the ear and can be used to differentiate conductive and sensori-neural hearing loss
using the Rinne and Weber tests.

To carry out the Rinne test, place a sounding tuning fork on the patient’s mastoid process
and then next to their ear and ask which is louder. A normal patient will find the second
position louder.

To carry out the Weber’s test, place the tuning fork base down in the centre of the
patient’s forehead and ask if it is louder in either ear. Normally it should be heard equally
in both ears.
 o Rinne test - place tuning fork on the mastoid process

o Rinne test - place tuning fork beside the ear

o Webers test - place the tuning fork base down in the

centre of the forehead
16. The Glossopharyngeal nerve (CN IX) provides sensory supply to the palate. It can be
tested with the gag reflex or by touching the arches of the pharynx.

o Glossopharyngeal nerve examination

17. The Vagus nerve (CN X) provides motor supply to the pharynx.

Asking the patient to speak gives a good indication to the efficacy of the muscles. The
uvula should be observed before and during the patient saying “aah”. Check that it lies
centrally and does not deviate on movement.

18. The Accessory nerve (CN XI) gives motor supply to the sternocleidomastoid and
trapezius muscles. To test it, ask the patient to shrug their shoulders and turn their head
against resistance.
 o Sternocldeiomastoid muscle test against resistance

o Sternocleidomastoideus

o Trapezius muscle test against resistance

o Trapezius
19. The Hypoglossal nerve (CN XII) provides motor supply to the muscles of the tongue.

Observe the tongue for any signs of wasting or fasciculations. Ask the patient to stick
their tongue out. If the tongue deviates to either side, it suggests a weakening of the
muscles on that side.
 o Hypoglossal nerve examination
20. Thank your patient and wash your hands. Report any findings to your examiner.

- See more at: http://www.osceskills.com/e-learning/subjects/cranial-nerve-

examination/#sthash.7dB8AxWQ.dpuf