MRCP PACES Station 3 CNS Please examine the patients eyes and cranial nerves and discuss your findings. Skills: physical examination (A), identifying physical signs (B), differential diagnoses (D), clinical judgement (E), maintaining patient welfare (G). Suggested Action plan Introduce yourself to the patient and make a general inspection looking for clues, e.g. Scars, ptosis, asymmetry , etc. Position the patient carefully to enable you to conduct the examination best. Ask about hearing Make a careful assessment of acuity and visual fields Perform a fundoscopy if required Check the light reflex , corneal reflex and gaze . Inspect for wasting of temporalis and masseter. Physical Examination: Eyes and cranial nerves Introduce yourself - Hello .. I am Dr Verbal conscent - I have been asked to examine your eyes and also your nerves in your face and head is that ok? Cranial nerve I Olfactory nerve - First thing I would like to do Is start by asking you how is your sense of smell? Cranial nerve II Optic nerve - Visual field general - Next thing I would like to do is look straight at my face Can you see my face ok? ( patient - most of it) Which part you cant see very well? ( patient - your chin mouth) Visual Acuity - Next thing I would like to do I am going to check your vision using a reading chart Cover your right eye for me please And then I would like you to start reading the letters from the top of the chart down please Thats fantastic Can you cover up your other eye please Can you read the chart from the top Visual field in ALL 4 quadrant - I would like you to cover your right eye with right hand Keep looking straight to my nose Tell me when you can see my finger wiggling. From up wiggle doctors finger from left side Then from down wiggle from left side Keep your hand where it is Tell me when you can see my finger wiggling Wiggle finger from up toward FOV from right side Tell me when you can see my fingers wiggling Wiggle finger finger from down toward FOV from right side Other eye Tell me when you can see my fingers wiggling Wiggle finger from up toward FOV from left side Tell me when you can see my fingers wiggling Wiggle finger from down toward FOV from left side Keep your hands where it is Tell me when you can see my finger wiggling Wiggle finger from up toward FOV from right side Tell me when you can see my fingers wiggling Wiggle finger from down toward FOV from right side Pupillary light response - I am now going to shine a light in your eyes Could you take your glasses off for me And look straight ahead the wall please Looking straight ahead Pupillary response Red reflex Fundoscopy examination - Optic disc All four quadrant I will come around and look into your other eye now Keep looking straight ahead for me And look straight into light Thank you very much Cranial nerve III, IV, VI Oculomotor, Trochlear, Abducens: Eye movement - What I am going to do now is I am to check movement of your eyes Do you want to pop in your glasses for me I want you to Look straight on my finger and I would like you to follow my finger with your eyes but keep your head still Tell me if you have double vision Try to keep your head still H test What I would like you to do now Look at your left then your right then to your left then right Now look at my nose Now look straight up the ceiling then straight down on the floor then up straight up the ceiling then straight down the floor Thank you very much Cranial nerve V Trigeminal 3 branches sensory supply: I am going to check the sensation on your face now I would like you to tell me Can you feel me touching your forehead Same on the both sides? Can you feel me touching your cheeks Is it feel Same on the both sides? Can you feel me touching your chin Does it feel same on the both sides? Motor supply of Trigeminal nerve V: Clench your jaw - check masseter and temporalis muscle Open your jaw up - check strength of mandible Corneal Reflex of Trigeminal nerve V: I am going to test your blink reflex now Could you please take off your glasses for me I want you to look up and over my hand- right eye corner I want you to look up and over my hand - left eye corner Suggested deductions Restriction of visual fields - tunnel vision Dark pigmented spicules around the periphery of the retina Pale optic discs with attenuation of the arterioles Diagnosis: Retinitis Pigmentosa Key findings : A really helpful thing is to ask the patient to do at the beginning of the cranial nerve examination It is to ask whether they can see your whole face I mean cases there may be hemianopia Patient may then straight tell you they can see half your face You can get answer immediately In this case here this gentleman said he couldnt see my chin and my mouth suggesting there is some Restriction of his visual field Then I went to examine his visual field expecting to find something And indeed we found Marked restriction of his visual field Throughout all his visual field The test of visual field can be quite easily go wrong It is quite important to try position yourself approximately a meter away from the patient and making sure that your hand with your finger wiggling is halfway between you and the patient so that you both quite have equal chance of seeing it fairly Another interesting thing to notes and in this case despite the facts that there is severe restriction of the visual field , the visual acuity as measured by the snenel chart was essentially normal which is obviously expect to see in such case . Case Presentation : Mr ... Has retinitis pigmentosa On ophthalmoscopy there was dark pigmented spicules scattered throughout the periphery of his retina I have also noted Pale optic disc bilaterally And Attenuated arterioles Additionally on testing of his visual field there is general restriction of his visual field , so only his very central vision is remain unimpaired Visual acuity is normal Being 6/6 on on left eye and slightly reduced 6/9 on his right eye I didnt noticed any evidence of hearing loss which is often be associated with retinitis pigmentosa I would like to go onto examine his rest of the neurological system and examine him in general to look for evidence of any other syndromes that are associated with retinitis pigments. Case critique - This is another case where the diagnoses where the diagnoses is relatively straight forward in findings of retinitis pigmentosa on retinal examination where very marked. So therefore you need to explain the examiner whats the diagnosis is and why you come to that diagnosis. You should mention that you tested for visual filed restriction and found all but the central vision to be severely restricted. It is worth noting his visual acuity were fairly normal and you expect that. In the case of retinitis pigmentosa where there is many known association I think its worth telling the examiner you would like to go on and examine the patient fully and look for the other associations certainly within the cranial nerves you must mention that You check for deafness but you didnt find it as it is common associated with retinitis pigmentosa. In instances such as Usher syndrome . Certainly rest of the neurological examination may reveal changes such as neuropathy which is in refsums or Abetalipoproteinaemia. Or may show signs such as polydactyly which is seen in Laurence moon Biedl syndrome. Which conditions are associated with retinitis pigmentosa? Usher syndrome Refsums syndrome Kearney Sayre syndrome Laurence Moon Biedl syndrome Which findings would you expect to see in association with retinitis pigmentosa? Cataracts Sensorineural deafness is seen with RP in Ushers syndrome Peripheral neuropathy is seen in RP in Refsums disease and Abetalipoproteinaemia Polydactyly occurs in Laurence - Moon - Biedl syndrome Which of the following clinical observations would you not expect in retinitis pigmentosa? Restriction of visual fields Normal pupillary reactions Poor vision in low light conditions Dark pigment in the peripheral retina Central scotoma - Answer Which of the following is not associated with optic atrophy? Retinitis pigmentosa Multiple sclerosis Giant cell arteritis Vitamin C deficiency - Answer Vitamin B 12 deficiency
Posted on: Sun, 09 Nov 2014 15:27:17 +0000
Trending Topics
Recently Viewed Topics
© 2015