Daniel Huddart 25 off with the online code WSREVMED25 Valid until 31 August 2020 Only at wwwworldscientificcom RevMED 300 SBAs in Medicine and Surgery By Lasith Ranasinghe amp Oliver Clements ID: 916389
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Slide1
Cranial Nerves & Ophthalmology
Daniel Huddart
Slide225% off
with the online codeWSREVMED25Valid until 31
August 2020
Only at www.worldscientific.com
RevMED
: 300 SBAs in Medicine and Surgery
By Lasith Ranasinghe & Oliver Clements
(
Imperial College London, UK
)
Slide3Overview
DISCLAIMER: MedED does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however this guide should not be used to replace formal ICSM teaching and educational materials.
Revise cranial nerves examination
Signs of different neurological conditions
Some smaller topics:
Bell’s Palsy
Horner’s Syndrome
Neurofibromatosis
Ophthalmology needed for year 3
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Slide4Please Note
I don’t like to read off slides, so you will find what I say in the notes section of the slides Some of these signs you would be very unlikely to be given in your OSCE, but perhaps as an SBA – will try to highlight this as we go throughFor you keenos have included more minor, textbook topics on slides to read afteric_meded
Slide5Approaching a neuro question
What?Where?Why?What next?ic_meded
Slide6Approaching a neuro question
What? –symptoms/signsWhere? –anatomyWhy? –pathophysiologyWhat next? -investigationsic_meded
Slide7A lot to do!
I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII FacialVIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal
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Slide8A lot to do!
I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII FacialVIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal
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Slide9Key ones to know more in depth
OpticOculomotorFacialVestibulocochlear ic_meded
Slide10Conditions affecting any cranial nerve
Diabetes mellitusMSTumoursSarcoidVasculitisSystemic lupus erythematosusSyphilisic_meded
Slide11Introduction
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Slide12General Inspection
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Slide13Olfactory
Unlikely asked to test properly in OSCEAnosmia Differentials:Ageing Traumatic Brain InjuryParkinson’sAlzheimer’sTumour
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Slide14SBA 1
A 24 year old woman presents to her GP with a red painful eye with blurry vision. She has noticed a lot of clear discharge coming from her eye. She has otherwise been well, apart from some recent diarrhoea. What is the most likely diagnosis?Viral ConjunctivitisBacterial ConjunctivitisAnterior Uveitis Posterior UveitisClosed angle glaucomaic_meded
Slide15Optic
A lot to go through on this one:Acuity ColourFieldsReflexesFundoscopyCan inspect now or later
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Slide16Optic - Colour
Ishihara PlatesUnlikely in OSCE settingLooking for colour blindnessic_meded
Slide17Optic - Acuity
Key things to consider when formulating differentials:Unilateral or BilateralSudden or progressivePainful or PainlessYoung or oldRisk factorsic_meded
Slide18Optic Acuity
If patient wears glasses/contact lenses, should be assessed first without and then with6 metres from chartOne eye at a timeRecord lowest line able to read (with 2 or fewer mistakes)Acuity is distance of chart as numerator over number of lowest line read as denominator ic_meded
Slide19Optic Acuity
Differentials:Refractive errorOcular Mediacataracts diabetesRetinaage related macular degeneration diabetic retinopathyOptic neuropathyMSischaemia ic_meded
Slide20Conjunctivitis
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Slide21Conjunctivitis
Inflammation of the conjunctiva Symptoms Conjunctival Hyperaemia – “pink eye”ChemosisCrust and Discharge “Foreign body sensation”Photophobia Causes – Bacterial, Viral or AllergicDiagnosis most often clinicalic_meded
Slide22Bacterial vs Viral
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Slide23Bacterial vs Viral
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Slide24Allergic Conjunctivitis
Young adults
Type 1 Hypersensitivity (IgE)
pollen
dust
Chemical scents
Conjunctivitis plus:
Itching
Sneezing
Red, watery and oedematous eye
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Slide25Cataracts
Clouding of the lens of the eyeVisual impairment and glare, halos around lightsPainlessO/E – reduced red reflex and clouding of the lensMainly clinical diagnosis ic_meded
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Slide27Visual halos
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Slide28Cataracts
Over 90% is age related
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Slide29Glaucoma
Vision loss resulting from optic nerve damageNormally due to increased intraocular pressure 2nd leading cause of blindness worldwideDamage to optic disc leads to progressive peripheral visual loss For an acutely, red painful eye you must rule out closed angle glaucomaic_meded
Slide30Glaucoma
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Slide31Pathophysiology
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Slide32Glaucoma
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Slide33Glaucoma Investigations
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Slide34Uveitis
Inflammation of the uveaAnteriorPosterior Complete IntermediateCausesSystemic InflammationInfectionAnterior and Posterior most important to understandic_meded
Slide35Uveitis
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Slide36Uveitis Investigations
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Slide37SBA 1
A 24 year old woman presents to her GP with a red painful eye with blurry vision. She has noticed a lot of clear discharge coming from her eye. She has otherwise been well, apart from some recent diarrhoea. What is the most likely diagnosis?Viral ConjunctivitisBacterial ConjunctivitisAnterior Uveitis Posterior UveitisClosed angle glaucomaic_meded
Slide38SBA 1
A 24 year old woman presents to her GP with a red painful eye with blurry vision. She has noticed a lot of clear discharge coming from her eye. She has otherwise been well, apart from some recent diarrhoea. What is the most likely diagnosis?Viral ConjunctivitisBacterial ConjunctivitisAnterior Uveitis Posterior UveitisClosed angle glaucomaic_meded
Slide39Fields
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Slide40Fields
Technique is important here!Directly facing patient on same level When they cover left eye, cover your right and vice versaMust look into your eye and not move head or eyesSay yes when they see your fingertip wigglingAs bring in fingertip must be equal distance between you and patient ic_meded
Slide41Visual Fields
Monocular vision lossBitemporal HemianopiaContralateral homonymous hemianopiaContralateral superior quadrantinopiaContralateral inferior quadrantinopia Contralateral homonymous hemianopia with macular sparingic_meded
Slide42Simplified
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Slide43Causes
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Slide44Post chiasmal
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Slide45Neglect
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Slide46Reflexes
Direct pupillaryConsensual pupillary Swinging lightAccommodationic_meded
Slide47Pupillary light reflex
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Slide48Relative afferent pupillary defect
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Slide49Horner’s syndrome
Differentials:Carotid artery dissectionPancoast tumourBrainstem stroke/tumour ic_meded
Slide50Horner’s syndrome
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Slide51Horner’s syndrome
Investigations:CXRCT HeadMRI/ MR AngiographyManagement:Referral!ic_meded
Slide52Fundoscopy
Other conditions or signs where ophthalmology may be relevant:Diabetic retinopathyHypertensive retinopathyPapilloedema ic_meded
Slide53Eye movements
Nystagmus
Diplopia
Pain
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Slide54SBA 2
A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:Internuclear ophthalmoplegia Anhidrosis, miosis and ptosisDown and out pupilMydriasisDown and out pupil with mydriasisic_meded
Slide55ic_meded
Slide56Oculomotor palsy
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Slide57Occulomotor palsy – read if keen
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Slide58Trochlear Palsy
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Slide59Abducens palsy
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Slide60Internuclear ophthalmoplegia – read if keen
When the patient’s gaze is directed away from the side of the lesion, the ipsilateral (adducting) eye will not adduct and the contralateral (abducting) eye demonstrates horizontal nystagmus
MS
Stroke
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Slide61SBA 2
A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:Internuclear ophthalmoplegia Anhidrosis, miosis and ptosisDown and out pupilMydriasisDown and out pupil with mydriasisic_meded
Slide62SBA 2
A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:Internuclear ophthalmoplegia Anhidrosis, miosis and ptosisDown and out pupilMydriasisDown and out pupil with mydriasisic_meded
Slide63Trigeminal
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Slide64Trigeminal
Light touch – cotton woolPinMasseter and temporalis – clench teeth togetherMasseter and temporalis – open mouth against resistanceCorneal reflexJaw jerk
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Slide65Trigeminal
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Slide66Trigeminal
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Slide67Trigeminal
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Slide68SBA 3
A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?StrokeBell’s PalsyMSRamsay Hunt syndrome Horner’sic_meded
Slide69Facial
give a big grin showing their teethblow out their cheeksscrew up their eyesraise their eyebrowsic_meded
Slide70Bell’s Palsy
Causes:idiopathiccompression of facial nerve within the facial canalinflammation, e.g. viral infectionherpes simplex type 1 or varicella zosterDiabetes is risk factorApproximately 7% of patients have a recurrenceic_meded
Slide71Bell’s Palsy
Investigations Serology - lyme, herpes, zosterManagement:Prevent corneal abrasions Steroids - prednisoloneic_meded
Slide72Ramsay Hunt syndrome
LMN facial nerve palsy due to varicella zoster Pain often a prominent featureother cranial nerves can be affectedvesicles in the ipsilateral ear, hard palate or the anterior two thirds of the tonguecan include deafness and vertigoIt should be suspected when pain is significant, especially in those aged over 60ic_meded
Slide73Facial
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Slide74Facial
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Slide75SBA 3
A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?StrokeBell’s PalsyMSRamsay Hunt syndrome Horner’sic_meded
Slide76SBA 3
A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?StrokeBell’s PalsyMSRamsay Hunt syndrome Horner’sic_meded
Slide77SBA 4
A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?MeningitisOtitis mediaForeign bodyMeniere's diseaseNeurofibromatosis type 2ic_meded
Slide78Vestibulocochlear
Gross hearingRinne’s Weber’s Vestibular testing:Turning testVestibular-ocular reflexic_meded
Slide79Weber’s
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Slide80Rinne’s
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Slide81Interpreting results
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Slide82Know this at the least
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Slide83Conductive hearing loss
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Slide84Sensorineural hearing loss
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Slide85Neurofibromatosis
Type 1Type 2InheritanceAutosomal DominantAutosomal DominantGeneNF1NF2Chromosome1722PresentationCafé-au-lait spotsFreckling in skin foldsNeurofibromasLisch nodulesSpinal scoliosisSensorineural hearing lossBilateral acoustic neuromas
Symptomatic by age 20Other featuresShort statureMild intellectual disabilityNo/fewer café-au-lait spotsTinnitus/vertigo possibly
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Slide86Neurofibromatosis type 1
To make the Dx: Pre-pubertal >5 spots of >5mm each
Post-pubertal >5 spots of >15mm
each
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Slide87Neurofibromatosis
Acoustic neuroma = Vestibular Schwannoma ic_meded
Slide88Turning test
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Slide89SBA 4
A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?MeningitisOtitis mediaForeign bodyMeniere's diseaseNeurofibromatosis type 2ic_meded
Slide90SBA 4
A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?MeningitisOtitis mediaForeign bodyMeniere's diseaseNeurofibromatosis type 2ic_meded
Slide91SBA 5
A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?StrokeParkinson’sMotor neuron disease MSAchalasiaic_meded
Slide92Glossopharyngeal and Vagus
Soft palate and UvulaGag reflexCoughSwallowAssess speech quality and volume for hoarseness and quietnessic_meded
Slide93Accessory nerve
Shrug shoulders and resist as push down – trapezius Turn head to side and resist pushing/pulling it to other – sternocleidomastoidic_meded
Slide94Hypoglossal
Inspection:WastingFasciculations Protrude tongue DeviationPush tongue against inside of cheek poweric_meded
Slide95Bulbar Palsy
Gag reflex – absentTongue – wasted, fasciculationsPalatal movement – absentJaw jerk – absent or normalSpeech – nasalEmotions – normalOther – signs of the underlying cause, e.g. limb fasciculations.ic_meded
Slide96Pseudobulbar Palsy
Gag reflex – increased or normalTongue – spasticPalatal movement – absentJaw jerk – increasedSpeech: “a monotonous, slurred, high-pitched, ‘Donald Duck’ dysarthria” Emotions – labileBilateral upper motor neuron (long tract) limb signsic_meded
Slide97Differentiating
Pseudobulbar palsyBulbar palsyUMNLMNV, VII, X, XI and XIIX, XI and XIIStroke of internal capsuleMSMotor neuron diseaseMotor neuron diseaseGuillain-BarreSpasticity, hyperreflexiaFasciculations, wasting, hyporeflexia
Donald duck speechNasal speechEmotions labile
Emotions normal
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Slide98SBA 5
A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?StrokeParkinson’sMotor neuron disease MSAchalasiaic_meded
Slide99SBA 5
A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?StrokeParkinson’sMotor neuron disease MSAchalasiaic_meded
Slide100Summary
I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII FacialVIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal
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Slide101Summary
Revise cranial nerves examinationSigns of different neurological conditionsSome smaller topics:Bell’s PalsyHorner’s SyndromeNeurofibromatosis ic_meded
Slide102Thank you for listening!
Questions: dh2314@ic.ac.ukFeedback! – ic_meded