Page 94 Guide to Pain Management in Low-Resource Settings

82 Paul Kioy and Andreas Kopf

What does examination of the (8th nerve) system and occasionally cerebellar lesions,
cranial nerves tell us? although mentioned here with the eye motor nerves.
Th e fi fth nerve is examined by assessing sen-
Th e fi rst cranial nerve is commonly examined using ar- sation in the face and part of the scalp in front of the
omatic non-irritant or pungent materials, such as soap, ear, together with motor activity of muscles of masti-
which is easily available. Each nostril should be exam- cation (jaw clenching and opening against resistance).
ined separately with the other blocked, and the patient Fast (touch) and slow (pinprick) sensations are handled
is asked to determine the smell by sniffi ng. Abnormali- separately as they follow diff erent pathways and may be
ties of smell are more commonly from local pathologies impaired diff erentially. Th e corneal refl ex has its aff erent
in the realm of otorhinolaryngology, but they can occur arm in the ophthalmic division of the trigeminal nerve
with base of skull and anterior fossa pathologies such as and would normally be included as part of its assess-
fractures and tumors. ment.
Examination of the second cranial nerve is the Th e seventh nerve is examined by observing
most involved, but it aff ords the best source of informa- for facial symmetry at rest and when the patient at-
tion about intracranial pathology. Th e optic pathways tempts to wrinkle the forehead (lift the eyebrows), close
traverse the whole of the brain from the frontal to the the eyes, show the teeth, or blow out the cheeks. Taste,
occipital pole, with the optic radiation opening out to which is also a function of the seventh nerve, is rarely
traverse the parietal as well as the temporal lobes. As- tested routinely, but it can be tested in the anterior two-
sess visual acuity roughly using a newspaper, which con- thirds of the tongue using sugar or salt on the protruded
veniently has type of diff erent sizes. More accurate vi- tongue.
sual acuity measurements can be done using hand-held Th e eighth nerve function may crudely be tested
Snellen charts (i.e., eye charts). using a ticking watch or by rubbing the fi ngers near the
Visual fi elds can be examined using the con- ear. If a hearing defi cit is suspected, ensure the patency
frontation method in all four quadrants separately for of the external auditory meatus and then carry out more
each eye. Th e method compares the visual fi elds of the elaborate tests such as Weber’s test or Rinne’s test to
patient with that of the examiner using a colored ob- distinguish conduction from nerve deafness, or refer the
ject—usually a pin head advanced from the periphery patient for more sophisticated audiometry.
of each quadrant. More accurate assessment can be car- Th e ninth, 10th, and 12th nerves are examined
ried out using perimetry or tangent screens. together. One should note the presence of dysphonia,
Examination of the optic fundus may reveal in- palatal movement symmetry (when the patient says
valuable information regarding raised intracranial pres- aaah), the gag refl ex, and tongue movement symme-
sure and the state of the arteries. All patients with head- try. Pharyngeal sensation may be tested using a wooden
aches should have a funduscopy done. Th e state of the probe tipped with cotton wool, testing each side sepa-
arteries, silver-wiring, venous pulsations, disc color and rately, normally as part of the gag refl ex.
margins should be examined and noted together with Th e 11th nerve or the spinal accessory nerve is
hemorrhages and exudates if present. normally examined with the rest of the motor system.
Th e examination of the papillary reactions and Th e movement of shrugging the shoulders and turning
eye movements yields further information on the sec- the neck against resistance applied to the side of the jaw
ond, the third, the fourth, and the sixth cranial nerves. will give an indication of any weakness in the trapezius
Pupil size, shape, and reaction should be checked using or the sternocleidomastoid muscles, respectively.
a bright light for direct, consensual, and accommoda-
tion reactions and noting the symmetry and prompt-
ness of the responses. Check for ptosis (eyelid droop), How do I examine the motor and
and note whether it is partial or complete. Eye move-
musculoskeletal system?
ments should be tested in all directions and include
tests of conjugation. Th e presence of nystagmus should General observation for muscle wasting or hypertro-
be noted and described, remembering that nystagmus phy, deformities, posturing, and presence of involun-
at extremes of lateral gaze may be normal. Abnormali- tary movements (fasciculations, tremors, chorea, or
ties of nystagmus refl ect abnormalities in the vestibular athetosis) should be done. When necessary, changes