Step-by-Step OSCE Guide

GETTING STARTED

1. Perform hand hygiene and wear PPE if required.
2. Introduce yourself: “Hi, I’m Jamie, one of the advanced clinical practitioners.”
3. Confirm the patient’s full name and date of birth.
4. Explain the examination: “I’d like to check the nerves that control movement and sensation in your face and head. It’ll involve looking at your eyes, face, hearing and some movements.”
5. Gain verbal consent and ensure a chaperone is present.
6. Ask if the patient has experienced any visual, sensory or balance problems.
7. Position the patient sitting upright in a chair.

GENERAL INSPECTION

8. Look for any visible abnormalities: facial asymmetry, ptosis, abnormal eye movements, hearing aids, slurred speech.

CRANIAL NERVE I – OLFACTORY

9. Ask if the patient has noticed any recent changes in their sense of smell.
10. Formal smell testing is rarely done in OSCEs unless clinically relevant.

CRANIAL NERVE II – OPTIC

11. Inspect pupils for size, symmetry and shape.
12. Test visual acuity (Snellen chart).
13. Assess visual fields (by confrontation).
14. Check blind spots (optional).
15. Test colour vision (Ishihara plates).
16. Test pupillary reflexes – direct and consensual response.
17. Perform the swinging light test for relative afferent pupillary defect (RAPD).
18. Test accommodation reflex.

CRANIAL NERVES III, IV, VI – OCULOMOTOR, TROCHLEAR, ABDUCENS

19. Inspect eyelids for ptosis.
20. Ask the patient to follow your finger in an H pattern – assess for diplopia or restriction.
21. Observe for nystagmus.
22. Assess for strabismus using light reflex and cover/uncover tests.

CRANIAL NERVE V – TRIGEMINAL

23. Test light touch over forehead, cheek and jaw.
24. Palpate masseter and temporalis muscles during jaw clenching.
25. Test jaw jerk reflex if appropriate.
26. Test corneal reflex (only in advanced or formal exams).

CRANIAL NERVE VII – FACIAL

27. Ask about any changes in taste or hyperacusis.
28. Observe facial symmetry at rest.
29. Ask the patient to raise eyebrows, close eyes tightly, puff cheeks and smile.

CRANIAL NERVE VIII – VESTIBULOCOCHLEAR

30. Test hearing with whisper or finger rub.
31. Perform Rinne’s test (air vs bone conduction).
32. Perform Weber’s test (lateralisation).
33. If needed, assess balance (Romberg’s, head impulse test).

CRANIAL NERVES IX & X – GLOSSOPHARYNGEAL & VAGUS

34. Inspect the palate – ask the patient to say “ahh” and watch for uvula deviation.
35. Listen to the patient’s voice for hoarseness.
36. Ask the patient to cough.
37. Swallowing can be assessed or a gag reflex tested if necessary.

CRANIAL NERVE XI – ACCESSORY

38. Ask the patient to shrug shoulders against resistance.
39. Ask them to turn their head against resistance – assess sternocleidomastoid strength.

CRANIAL NERVE XII – HYPOGLOSSAL

40. Inspect the tongue for wasting, fasciculations or deviation.
41. Ask the patient to stick out their tongue and move it side to side.
42. Test tongue strength against the inside of each cheek.

CLOSING THE EXAM

43. Thank the patient and help them redress.
44. Perform hand hygiene.
45. Summarise your findings clearly.
46. Suggest appropriate next steps – e.g. full neurological assessment, MRI, ENT referral.

A systematic cranial nerve examination helps detect subtle neurological deficits that might otherwise be missed. Confidence comes from repetition and clinical context.