IC3 OSCE Cranial Nerves II-VI
“This is a neurology station. You have 5 minutes to examine cranial nerves two to six. I will then ask you to present your
findings and answer a question.”
Examination Expected/Normal Comments Potential/Abnormal Comments
Introduction
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent ‘Hi my name is X. I’m a third year medical
• Introduces self with name and level, student at RCSI. What’s your name? Nice
explains what he/she will be doing and to meet you. I’ve been asked to examine
obtains consent for same
your face today. That will involve
examining your vision and eye movements
and checking sensation in your face.
Would that be ok?’
Position and exposure ‘Mr/Mrs A is appropriately positioned and
• Patient seated exposed for this examination.’
Enquires about pain ‘Are you in any pain?’
• Prior to examining
General Inspection & Closer Inspection
Performed from end, then right side of bed ‘On general inspection Mr/Mrs A appears Glasses, enucleation
Inspects for well. There is no facial asymmetry and Facial asymmetry, wasting
o Patient eg. facial asymmetry Mr/Mrs A is not wearing glasses.’ Craniotomy/facial scars
o Equipment such as glasses Ptosis, Proptosis, Anisocoria
Cranial Nerve II
Visual Acuity
Assesses with Snellen chart. Visual Acuity
If unable to read chart, proceeds to
‘Visual Acuity is normal in both eyes’ Vision is reduced – hypermetropia, myopia,
finger counting, then light perception.
absent.
Quantify visual deficit – can see fingers,
Visual Fields light etc.
Confrontational testing
o Asks patient to cover one eye at
Visual fields
time with hand ‘On confrontational testing, visual fields
Bitemporal hemianopia
o Examiner seated directly across are intact in all 4 quadrants of both eyes’
o Optic chiasm lesion, pituitary
from patient
tumour
o Asks patient to direct gaze to
Unilateral field loss
corresponding eye of examiner
o Optic nerve lesion,
o Examiner holds up number of
tumour/vascular
fingers peripherally, equidistant
Homonymous hemianopia
between themselves and patient
o Optic tract to occipital cortex,
o Target starts outside visual field
vascular/tumour
then moves slowly to more central Inferior/superior quadrantanopia
position until patient confirms
visualization of the target
o Asks patient to correctly identify the
number of fingers
o All 4 quadrants (upper and lower,
temporal and nasal) tested
Offers to perform fundoscopy, assess
colour vision and assess blind spot.
Cranial Nerves II&III
Comments on pupil size and symmetry Pupils are unequal in size – Right pupil is X
Direct & Consensual light reflex mm & Left pupil is Y mm
With a pocket torch shines light from Direct & Consensual light reflex
side into one of pupils to assess No /sluggish response to direct or
reaction to light (direct). consensual light testing
Observes reaction of other pupil (cons) ‘Both pupils are equal and reactive to RAPD
RAPD light. Pupillary constriction in response to RAPD present (Marcus-Gunn)
Swinging light test – moves torch from accommodation was normal and there Accommodation
pupil to pupil in arc, observes for was no evidence of RAPD.’ Accommodation impaired/absent (lesions
normal constriction of both pupils of ipsilateral optic nerve, ipsilateral CN3
Accommodation parasympathetics, pupillary constrictor
Asks patient to look into distance, then muscle, or bilateral lesions of the pathways
to focus on finger held near patient’s from optic tracts to visual cortex.)
nose. Observes for constriction of both (Argyll Robertson pupil– accommodation
“This is a neurology station. You have 5 minutes to examine cranial nerves two to six. I will then ask you to present your
findings and answer a question.”
Examination Expected/Normal Comments Potential/Abnormal Comments
Introduction
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent ‘Hi my name is X. I’m a third year medical
• Introduces self with name and level, student at RCSI. What’s your name? Nice
explains what he/she will be doing and to meet you. I’ve been asked to examine
obtains consent for same
your face today. That will involve
examining your vision and eye movements
and checking sensation in your face.
Would that be ok?’
Position and exposure ‘Mr/Mrs A is appropriately positioned and
• Patient seated exposed for this examination.’
Enquires about pain ‘Are you in any pain?’
• Prior to examining
General Inspection & Closer Inspection
Performed from end, then right side of bed ‘On general inspection Mr/Mrs A appears Glasses, enucleation
Inspects for well. There is no facial asymmetry and Facial asymmetry, wasting
o Patient eg. facial asymmetry Mr/Mrs A is not wearing glasses.’ Craniotomy/facial scars
o Equipment such as glasses Ptosis, Proptosis, Anisocoria
Cranial Nerve II
Visual Acuity
Assesses with Snellen chart. Visual Acuity
If unable to read chart, proceeds to
‘Visual Acuity is normal in both eyes’ Vision is reduced – hypermetropia, myopia,
finger counting, then light perception.
absent.
Quantify visual deficit – can see fingers,
Visual Fields light etc.
Confrontational testing
o Asks patient to cover one eye at
Visual fields
time with hand ‘On confrontational testing, visual fields
Bitemporal hemianopia
o Examiner seated directly across are intact in all 4 quadrants of both eyes’
o Optic chiasm lesion, pituitary
from patient
tumour
o Asks patient to direct gaze to
Unilateral field loss
corresponding eye of examiner
o Optic nerve lesion,
o Examiner holds up number of
tumour/vascular
fingers peripherally, equidistant
Homonymous hemianopia
between themselves and patient
o Optic tract to occipital cortex,
o Target starts outside visual field
vascular/tumour
then moves slowly to more central Inferior/superior quadrantanopia
position until patient confirms
visualization of the target
o Asks patient to correctly identify the
number of fingers
o All 4 quadrants (upper and lower,
temporal and nasal) tested
Offers to perform fundoscopy, assess
colour vision and assess blind spot.
Cranial Nerves II&III
Comments on pupil size and symmetry Pupils are unequal in size – Right pupil is X
Direct & Consensual light reflex mm & Left pupil is Y mm
With a pocket torch shines light from Direct & Consensual light reflex
side into one of pupils to assess No /sluggish response to direct or
reaction to light (direct). consensual light testing
Observes reaction of other pupil (cons) ‘Both pupils are equal and reactive to RAPD
RAPD light. Pupillary constriction in response to RAPD present (Marcus-Gunn)
Swinging light test – moves torch from accommodation was normal and there Accommodation
pupil to pupil in arc, observes for was no evidence of RAPD.’ Accommodation impaired/absent (lesions
normal constriction of both pupils of ipsilateral optic nerve, ipsilateral CN3
Accommodation parasympathetics, pupillary constrictor
Asks patient to look into distance, then muscle, or bilateral lesions of the pathways
to focus on finger held near patient’s from optic tracts to visual cortex.)
nose. Observes for constriction of both (Argyll Robertson pupil– accommodation
