Makindo Medical Notes

Related Subjects: |OSCE Eye Exam |OSCE Ear Exam |OSCE Abdominal Exam |OSCE Testicular Exam |OSCE Inguinal Exam |OSCE Upper limb Neurology |OSCE Lower limb Neurology |OSCE Face Neurology

👁️ Clinical Pearl: Always look at the pupils. 🙂 If hemifacial weakness is present → check the arm on same side. 🧠 Forehead sparing = think stroke. 😮 Difficulty closing the eye (not ptosis) = facial nerve palsy.

👋 Introduction

• 🧼 Wash hands before starting.
• Introduce yourself, confirm patient’s name & DOB.
• Explain purpose: testing motor + sensory function of the face, including pupils.
• Gain consent, ensure comfort, privacy, and good lighting.

🔑 Key Areas to Assess

• CN V (Trigeminal): Sensory in 3 divisions + motor to mastication. (Rarely gives “classic” neuro signs but important in OSCE).
• CN VII (Facial): Motor to muscles of expression. – Bell’s palsy 👉 whole face weak, cannot close eye, mouth droop, Bell’s sign. – Stroke 👉 forehead spared, look for limb weakness.
• Pupillary Function: Assess size, symmetry, light reflexes. – Complete CN III palsy 👉 full ptosis, dilated pupil, eye “down and out”.
• Horner’s Syndrome: Subtle triad 👉 mild ptosis, small pupil (miosis), anhidrosis.
• Other Conditions: Masked facies in Parkinson’s, wasting in myotonic dystrophy.

🩺 Examination Techniques

• Sensory (CN V): Light touch (cotton) + pinprick over V1, V2, V3. Compare sides.
• Motor (CN V & VII): Ask to raise eyebrows, close eyes tight, smile, puff cheeks. Look for asymmetry, drooping, weakness.
• Pupils: Inspect for size/shape, test direct & consensual light reflexes. Check for RAPD if suspected.
• Horner’s: Look closely for subtle ptosis + constricted pupil. Mention sweating loss (though not usually examined).
• Corneal Reflex: Touch cornea lightly → afferent CN V, efferent CN VII.

📊 Table: Major Nerves in Facial Examination

🧠 Additional Considerations

• Neuromuscular Dystrophies: Myotonic dystrophy → long thin face, drooping mouth, ptosis, weak eye closure.
• Parkinson’s Disease: Masked facies (hypomimia), reduced blinking, rigidity, tremor.

✅ Closure

• Thank patient, redress, maintain dignity.
• Summarise findings and suggest further tests if needed (neuroimaging, neurophysiology).
• 🧼 Wash hands again and document carefully.