 In an exam, what you'll be given is a slip of paper. Please do this, Primaelda, or the Primaelda, and one more to testing. So, C and one. As usual, check the patency of the nostril. Both sides, occlude one, breathe through the other, see the patency, occlude the other, breathe, see the patency. First, you confirm the patency. Second step, occlude one, put a strong smelling substance, coffee, peppermint, globe, or anything. Ask the patient to close his or her eyes. I'll be watching for this. So please close your eyes. Can you smell something? Let's say yes. Smell cigarettes. Yes. Smell this rice. No. I do. And then you close the other nostril. And can you smell something? If so, what it is. OK, fine. I'll keep an eye on that what you said just now. So that's C and one testing over. No. Come on. It's weird because I got a stronger sense of smell when I close my eyes. Everybody does. But remember, whenever you're doing any sensory testing, patients, I have to be closed. Point number one. Point number two, you have to test both the sides. So these are the two things which people miss out on during the exams, so be careful about that. C and one, over. Come to C and two, please. OK, this is the important one. This has got several components. One, the vision testing. That's called the visual acuity. I'm going to show it to you how it's done. Second one will be the ophthalmoscopy. And the third will be the visual field testing by confrontation methods. These three components are part of C and two. Color vision, we don't do. OK, now come here, please. This is our stainless chart. It is at a standardized distance. I've got a blue line here. What it is. I think we'll draw it again. It's just like a long distance. This line is approximately 24. This is not a long distance. Can you please put your signature here? OK, so you're going to show that? You're supposed to know that. This is 20 feet. This is standard. It is not random. Ask the patient to stand 20 feet away from the stainless chart. Please stand here. Want it? No, I'm looking at the chart. At 20 feet. You can come up with the feet touching the 20 feet. Now let me explain this chart to you. Imagine when you are asking the patient to do all these things. So that is a standardized patient. I'm the physician, and you are being tested. I mean, I'm watching you doing it. Explain to the patient, stand 20 feet away. Close one eye with the palm of your hand. Not with the fingers, because people will try to beep through the fingers. So close one eye with the palm of your hand, please. With the palm of your hand. If the patient has got glasses, keep asking to keep the glasses on. There are several levels here of different sizes, starting from largest to smallest. And when you come here, you will see next to this figure, a figure is written on your. If you don't want the video, just let me know. 200 feet, 100 feet, 70 feet, 50 feet. That is the figure which we want. Please follow me closely. Patient is standing very feet away. You will indicate to the patient just with your finger, and the patient will read that line. Then go to the next one, then to the next one, and to the next one. Till the patient can read one line and cannot read most of the letters of the last line. When the patient cannot read most of the letters, then you go back to the previous line where the patient had read all the letters. That line, whatever figure is written here, will be mentioned in your denominator. The numerator of your value will be 20 always. The denominator will be what is mentioned here. So now let's demonstrate how it is done. Please close one eye with your palm of your hand. So now we are testing her visual equity of her right eye. Please read this one. E, F, P, T, O, Z, L, P, E, D, P, E, C, F, D, E, D, F, B, Z, P. Even if the patient misses out one letter, it doesn't matter. One or two letters, it doesn't matter. Most of the letters they should be able to read. F, E, L, O, P, Z, D, P, E, D, E, F, P, G, E, G, L, E, F, D, E, G, F. I don't know. That one's hard to read. Oh, I definitely can't read. OK. So she read most of the letters in this slide. Against this is written here, 15 feet. So I will record her visual equity as on the right eye, B, A, right eye, 20 divided by 15. That brings me to the interpretation of this value. Come on, please. You're over 15 now? 15, 15. It means that she had read this line from 20 feet, which another normal person would have read from 15 feet. So you're super normal. Oh, OK. Suppose she had read only up to this line. Suppose this I'm saying just for the sake of demonstration. Against here is written 70 feet. So what would have been my interpretation? Visual equity right eye would have been 20 divided by 7. Meaning? Some other 7. She read it from 20 feet away. What a normal person would have read from? 75 feet away. Are we clear? Suppose she had read up to this line. What would have been written here 40 feet? What would have been my interpretation? 20 by 40. This is what I need from you. Meaning what? She has read from 20 feet, because this 20 is constant. Numerator is constant. She has read from 20 feet. What a normal person would have read from? 40 feet. 40 feet away. That means the patient's eyesight is poor. Did we get that? So in her case, it was other way round. It was 20 by 15. Meaning a normal person would have had to come at 15 feet to read this. She managed to read from 20 feet away. So you're 20 by 15. So this is the first part of the test, visual activity, BA. The similar component of this test in the next slide, please, is the sense, near vision, but we don't do it. Similar chart is held at 14 inches away, and you are asked to read from top to bottom. But we don't do that. That is the counterpart to the near vision. This was the distant vision test. Did we understand how to interpret this? Because in the exam, you will be asked to do this test, and you'll be asked to interpretation of it. Come to the next slide, please. Next is the visual field. Please come here. We don't do the instruments. We don't do the Lister's Perimeter, how pre-golden, and we don't do all this. Those who came here, please put your signature. We do only the visual field by the confrontation method. So stand appropriate distance away from the patient. When you see my fingers moving, please tell me. Ideally, if we start with both the hands, can you just keep looking straight? Patient's right eye, your left eye, patient's left eye, your right eye. Keep looking at my eyes. Can you see anything? Not moving at all. Can you see anything? You can? Can you? OK. OK, so this is the place, the limit, this vision. Keep moving inwards till the patient can identify what you are moving. You have to be able to think how many. Yes, that's what I'm saying. You first saw the movement. That's the limit. Keep looking straight till you can identify. Don't look sideways, please look straight. OK. So this is the middle. Similarly, start from the top. Keep looking straight, please. Tell me when you start seeing. OK. Start from the bottom. Keep looking straight. Can you see anything? So this is the starting from the limit and this is where she can identify. So lateral limit, inferior limit, superior limit, media limit. If there's a visual problem, then you do each eye. This is called the confrontation method. Fingers should be moving. So this is the visual field by confrontation. Please put a signature. The next test, please. I'm sorry. Yes? You find a problem when you're doing your room. Then suppose she says that she couldn't see the side. When you came very close, then only she saw it. That means there's a problem. Then you ask her to close her right eye and see the visual field of the left eye. So then that's when you do it? Absolutely. That's what I'm going to tell you how many fingers you have because it's very hard. Yes, I know. Tell you can identify the number of fingers. Initially, you'll see the movement and after that, you'll be able to identify the fingers. But the patient should keep looking. Right eye, left eye, left eye, right eye. Looking straight at you. This is the visual field by confrontation method. These are the instruments, but we don't do them in the lab. The next slide, please. Now we come to the ophthalmoscopic part of it. Again, this is something which you need to know. All of you'll have to do. So let me demonstrate the first parts of the ophthalmoscope for you and then how to do it. First thing, switch on. See the light there. Control for the light is here. Behind, those of you who can't see, please come. Make sure you see it. The control for the light is here, watch. When I turn this, I get different, different grids. Those are for various special tests. This is a slit-like examination. This is a blue color. You can see it's a blue color. This is a pinpoint light. This is a brighter light. This is an even bigger light and so on and so forth. You can keep turning it in either direction. What we do is we usually use this one. So first, determine which type of light you want. Yellow light is the one which we use. Then look at the intensity of the light on the palm of your hand. Again, by turning, till you get the right intensity. If it is too bright, it will produce spasm of the pupil, which is known as hippus. So we have to adjust the intensity. Step number two. Step number three, again with my index finger, you'll see there's a wheel here on the side. If the wheel normally, and when you're rotating the wheel, there's a small window here, where right now it is showing zero. This is the diopteric power of the ophthalmoscope. Diopter is the power of the eye, the refractive index of the eye. I just briefly mentioned it in the class. If I rotate it clockwise, I'll see a green figure coming here, one, two, three, green figure. This means that the diopteric power is going in a positive direction. If I rotate it anti-clockwise, I'll see a red figure coming here, one, two, three, and so on and so forth. That means it is negative. Minus one, minus two, minus three. What is the significance of this? Suppose let's say the patient has got, what is your power? Do you know your power? You don't know your number. Oh, it's like negative 4.5. It's minus 4.5, I think. OK. Let's put it, round it off, to minus 4, minus 5. Let's say minus power is 0. That means her eyeball is slightly bigger. So we have to put it at minus 5. Did we get it? Suppose she had said her power is plus 3, and I'm 0. Then we put it at plus 3. That means eyeball is a little smaller. So this is how you adjust it. So this is the meaning of this adjustment. But for all practical, for our FCM lab, we will keep it at 0. But you don't know their power. Keep it at 0. But if you know, and if you know your own power, suppose I am plus 1, and she's plus 3. What will I put it as? Suppose I am plus 1, and she's plus 3. Yes, we'll put it at plus 2. Because the difference between the two of us. So this is how we will adjust so that we can get a good vision. Because remember, when you're doing the ophthalmoscopy, you're looking at the fullness. You're looking at the inside of her eyeball. So this is the meaning of this directory power. So these are the two adjustments. We will see through this upper opening. This is the place where we see through. Now we will show you how to do the procedure. Can you come closer to this? I need this now. For this, I'll have to ask you to remove your glasses. And I'll have to remove my glasses also. So I'm just giving it at 0. Doesn't matter. I need you to be closer because this will not come so far away. Does it matter if I have contact lens? It doesn't matter. The glasses will obstruct the vision. Step number one. As I told you, my right eye, her right eye, my right hand. My left eye, her left eye, my left hand. Room should be ideally dark so that the pupils will be dilated. So I'm going to do the left. But I'll use the right hand. But I'll tell you the procedure for it. Yeah, it's all right. You can keep it like that so that people can see. First step. Adjust everything. Handle of the ophthalmoscope tilted 20 degrees laterally. First thing. Handle of the ophthalmoscope tilted 20 degrees laterally. And ask the patient to look over your shoulder. Can you look at Rachel? I'm so blind. OK, she's there somewhere. I see her. Keep looking at her. Patient should be looking over your shoulder at a mid-distance away. That way the pupil is slightly in a dilated position. This is the line of sight. We go 15 degrees lateral to the line of sight. Handle 20 degrees laterally. 15 degrees directed lateral to the line of sight. I'm going to use my left eye to see her left eye. Please keep looking there. OK. There's a ridge here. This one hitches against my eyebrow. There's a ridge here. Please follow. This one hitches against my medial side of my orbital margin. So I hitch this. Keep looking straight. Yes, yes, yes, yes, yes, yes, yes. I'm doing it right hand, but because I find it more convenient. Yes, I can see her optic disc beautifully. I can see the blood vessels. Keep looking straight. So after you identify the optic disc, keep looking straight, please. Don't look here and there. After you've seen the optic disc, keep looking straight, please. There you go. There you go. I can see the artery. I can see the vein. I can see the retina. So this is how you will do. You will do it. Go straight, optic disc, follow the blood vessels. See the retina. If possible, come to the macular. So these are the four things we look for. Optic disc, retina, blood vessels, macular. Is my normal? Is it normal? Yeah, till now it's normal. Whatever little I saw. So these are the procedures. You will do them and as you have problems, I'll explain it to you. OK, after we have done that, we switch it off. So this is the third part of the test. I agree. I should have used my left hand, but I followed all the steps. So this is 20 degrees, handle tilted, and 15 degrees lateral to the line of vision. Remember, line of vision. If you go 50 degrees lateral, you go straight to the optic disc. Remember, optic disc is of the temporal field. Yes. When you tell it, it looks like it's looking forward. If you're looking at a certain angle. No, she's looking straight at it. That is the line of sight. So your blade of your ophthalmoscope will be tilted 15 degrees lateral to her line of sight. Handle tilted 20 degrees away. This one fitted against my eyebrow, and I go straight into her pupil, and I start looking till almost the eyebrow touches the eyebrow. That is the reason we said left eye, left eye, right eye, right eye. Otherwise, eyebrows won't touch. Something else will touch, right? So that is the whole purpose of doing this. So these are the three parts of the visual testing. What did we do? Visual equity testing, visual field by confrontation, and ophthalmoscope. So these are the three parts. Come to the next slide, please. The next, yeah, this is the fundus. Same thing, the fundus of the findings. Colour vision we don't do. This was just for your interest, I put that. So we don't do the colour vision testing for FCM. Now, see, 3, 4, 6. Here again, we have a specific number of tests which are required for FCM, the first and foremost test, the edge test, so-called edge test. We combine, check, 3, 4, 6 together. That is the version testing, that both eyes together. Look straight at me. Follow my fingers. Right side, straight right. Keep following my fingers. We have to explain to the vision. Keep following my fingers. Up, down, back, straight left. Up, down. So what did we do? Right, up, down, left, up, down. This is called the so-called edge test, which is shown in the next slide, please. There, the first figure. You can see the full sequence of moments are shown. Can you come back to the? Yes, so this picture is the individual eye, but we did the shown in the one next slide. Yes, so this is the first test that we do, 3, 4, 6. The next test we do is the convergence test. We look for the convergence of the eyes. Start with a pen or pencil, a tip from a distance. As they move this closer to your face, please keep looking at the tip. And when the patient follows the tip of the pencil, look for the convergence of the eyes. You look for the convergence. Bring it up to, if necessary, up to five centimeters close to the eyes. I can visibly see the pupil's eyes converging. So this is the convergence test. So these are the two tests that we need to do. We don't test for the superior oblique and inferior oblique, but you know them. Superior oblique is, with eyes converged, look down. If you oblique eyes converged, look up, et cetera. And late-lag also we don't do. But if you're asked, you should be able to answer that. But these are the two tests that we do for 3, 3, 4, 6. The muscle testing. But remember, there's also a parasympathetic testing. Can we go to the next slide, please? In the parasympathetic component, again, we have two tests. Does anybody have a torch? Wonderful. So this, again, is done in a dark room with a bright light. So the patient should keep looking straight. Torch light. Torch light brought from the lateral aspect. Please keep looking straight. Torch light should be brought from the lateral aspect. In this case, I would like to ask you to remove your glasses. Bring the torch light from the lateral aspect and shine it on the pupil. There. When I shine it on the pupil, I saw the pupil constricting on that side. And I also saw the pupil constricting on the opposite side. So this was a direct light response that was a consensual light ripple response. Two points to be noted here. Dark room, bright light. The torch should not come too close to the eyes because then the near response will kick in. Did you understand that? We don't want the near response. We want the light response. Similarly, do it with the other side. Again, bring from the lateral side. Don't bring from the medial side because when you bring from the medial side, you've already stimulated the other eye, isn't it? So that we don't want. So bring from the lateral aspect and don't bring the torch too close to the eyes because then the near response may mislead your findings. So do it with the other side also. There, I can see both the pupils constricting. This is the near response. This is the light response. Can you have to light that, please? This is the first part of the parasympathetic testing. The second part of the parasympathetic testing is the near response. How do we go about it? Again, I'd like to see her pupils soon. I'm going to keep this tip of this pencil 10 centimeters from our nose and I'll keep it fixed there. This is done in normal light or bright light. So this way we have got the normal light on. You will ask the patient to alternately look at the tip and then look far away. Look at the tip, look far away. Look at the tip, look far away. And when the patient is doing that, look at the pupil. What do we see? When the patient looks here, the pupil's constrict. When the patient looks there, pupils dilate. First look at this eye, then ask the patient to continue doing the same thing and look at the other eye. So you look at the pupil of each eye when the patient is doing this job, looking at this and looking far away, looking at this and looking far away. Keep it constant at 10 centimeters. It is written there clearly and shown there. If you have any problems, please look at the pictures. So I'm going to hold this at a particular distance away from your face. I would ask you to look at this and immediately look far away. And then look at this and look at far away. Just keep doing that for a few times. Look at this, look far away. Look at this, look far away. Look at this, look far away. Look at this, look at far away. When the patient is doing that, you look for the pupil of constriction. When the patient looks far away, look at that. That is the near-response. So we have tested the pupil of constriction with light. We have tested the pupil of constriction with near-response, clear? So these are the two components. Yes, Josh? Yeah, they just look far away, that's all. They immediate to the pupil there. Same line of patient. That's why you have kept it right in the middle. Patient looks here, patient looks far away. Patient looks here far. So when the patient focuses here, the pupil is constricted. And when the patient looks far away, that's what you see in the mirror. But this is done in a normal light. The previous one was done in a dark room with a bright light. So these are the two components of CN3, parasympathetic and the motor component. Can we have the next slide please? CN5 testing. Again, two components, motor sensory. Let's do the motor first. I'll ask you to clench your teeth hard. When the patient is clenched his or her teeth hard, you palpate the meseta and palpate the temporalis, both the sides. Motor done. Sensory. Light touch, pain, temperature. If you're given a toothpick or if you're given a pin, you can do pin prick. But for all practical purposes, you will not be given the pin prick. You will be not given the temperature. Even though some of you would like to do the caloric test, you will not be given that. You will be given only the cotton wool. There's a stick with the cotton wool or you'll be given the cotton wool. This is the light touch. Again, the same two policies. Ask the patient to close his or her eyes and test both the sides. Don't forget this. So what I'm going to do is I'm going to touch your face in certain areas and you'll have to tell me whether you can feel the touch or not and whether you feel both sides equally or not. Okay, next slide to the patient. Please close your eyes. Actually, your hair should be out of the way. You know why? Because the hair itself is giving you that sensation. So the three representative areas are V1, V2, V3. It's shown there in the circle form in that third picture there. Do you feel the same on both the sides? Now? No. Sure? Okay. So just to test, you need not touch and ask, do you feel anything or not? So this is the sensory testing and the motor testing of CN5. Remember, I'll see whether you're asking the patient to close her eyes and whether you're testing both the sides or not. Sensory testing is always done with these two caveats. Next slide, please. We do not do the corneal reflex. Even in clinical skills assessment and even in CS, step two CS, you are not expected to do, but you must know it. Ask the patient to look immediately and bring the cornea, light touch, cotton wool from the lateral aspect and touch the cornea. You will be asked to explain it, but not do it. The first picture is the correct one, the second picture is the wrong one. You will not do this, but you may be asked to demonstrate what other means of testing you have. So we'll come to the next slide, please. CN7. Look up, please. Look surprised. Look surprised. Rinkly of forehead. Rinkly of forehead. There, look at the corrugated, corrugations of the- Wrinkles? Wrinkles of the forehead. Corrugations. Look up, look up, look up. There. There. Okay, frown at him. Frown at, whoever is your- Can I put my glasses on? Yes, whoever you want to frown at. There, look at the vertical ridges of the forehead. Number one. Number two. I'll have to ask you to remove your glasses again. Close your eyes tightly. Tightly. And try to open them apart. Price them apart. There's a third rest. Fourth one. Bloody cheek, please. Try to puncture it. Number five. Keep your face normal, please. Look at the nasolabial furrow. Look at the angle of the mouth. Symmetry. Number six. Just show your teeth. Look at the symmetry. Equal number of teeth should be visible on either side. Mind you, in the previous group or the other semesters, I noticed people get confused between clenching your teeth and showing your teeth. What is the difference? I will look for these things in the exam. Clenching your teeth, you're testing CN five. Showing your teeth, you're testing for CN seven. Are we clear about this difference? So I just asked you to do, I didn't ask you to clench your teeth. I said, just show me your teeth. Or just smile. Just say a smile, that's all. Lift up the skin of your, do this. This, this. There. That is smile. So we have tested for CN seven. Again, we do not test for taste, but you may be asked. So you should say, I will test with salt, sweet, bitter, or this thing, something, salt. What is it, other one? Umami. Sour. On anterior two-thirds of the tongue, either side. But we don't do it. So we are done with CN seven. Next slide, please. CN eight. The good news is for FCM, we do not do vestibular testing. So we won't do the caloric test. We won't do the ocular cephalic reflex test. We will not do the bad knees chair test. We will do only the tunic bone test. And I'm going to quickly demonstrate what I've already shown to you. We do the renails and the Weber's test. I'm going to put this on behind your ear. You tell me when you hear it and tell me when you stop hearing it. And then I'm going to put this in front of your ear and you tell me whether you hear it or not. Can you move your head back, please? Thank you. It's okay. I think you'll have to hold it there with your other hand. Yes, that's better. I guess it's tight. Make sure when you're doing the tap, don't tap it on the heart, sir, object. Tap it on something firm or relatively soft. And make sure, yes, I saw somebody holding like this. This is also a mistake because you're dampening the vibrations. Keep telling me when you, tell me when you don't hear it anymore. So this is renails positive. Air conduction is better than bone conduction. It's very important to explain to the patient so that you get a good correct response. Next, I'm going to do the same thing. I'm going to put it here. Tell me whether you hear it equally on both the sides or you hear it more on one side or the other side. This is Weber's test equally lateralized both sides. So these are the two tiny four tests that you'll be especially to prove. Can I have the next slide, please? So we have done all these. We have done this one. We have done. It's all from your glass. Yes? Air conduction is better than bone. Test is negative. That means bone conduction is better than air conduction. We raise negative. So positive is air conduction is better than bone, which is normal or sensory neural. And Weber's is lateralization, conductive deafness, opposite side sensory neural deafness. Nine and 10 together. Now what I'm going to do is can you just open your mouth? Again, I may need the torch. Sometimes you cannot see inside, so you have to shine the torch. And just, I know you have that. Just open your mouth. And just say, ah. Yes, please say softly, ah. Say again, ah. OK. You ask the patient to say ah softly, or you on. We look for three things. One, movement of both the soft palate, arching up, symmetrically. Movement of the uvula back in the midline. Three, movement of the pharyngeal wall closes the medial. Again, please say ah. Ah. Say again. Ah. Look for these three things. You will not do the gag reflex, but you will be asked. So you say, I'll take a tongue depressor or a spatula, wooden spatula, and I'm going to stimulate the posterior one-third of the tongue, or the posterior pharyngeal wall on one side, and I will look for the movement of the pharyngeal wall on both the sides. Clear? You won't do it, but you'll ask the patient. And the third part of the test will be, ask the patient to say some hard words, like guh, and look for the sound, quality of the sound. So can you say guh? Guh. Say guh, please. Guh. Sorry, my gum. I don't want to fly on you. I'm sorry. Guh. Yes. Look for the quality of the sound, hoarseness, and nasal quality. Say a nine-ten over. Next slide, please. C-11. I'll ask you to turn your head to one side. Please look at Abed and keep looking at him. I'm going to try to prevent you from looking at him, but you will insist on looking at him. So what did I test? Right side. Similarly, I'm going to ask you to look at Fadi. You will insist on looking at him, and I'll try to prevent you from looking at him. What did I test? SCM. Which one? Left. Next, please try to touch your chin to your chest. Wait, wait, wait, wait, wait, wait. Yes, look down, please. Try to touch your chin. Yes. I tested both sides, I'm against you. Can I ask you to stand up, please? Even though the picture says from the front, I prefer it, and it is better to do the trapezius test from behind. Can you turn around, please? Look at the symmetry of the shoulder. If it's that side, it's more horizontal or flattened out. We test only the supia fibers. If we don't test the media fibers, we then test the inferior fibers. I'm going to ask you to lift your shoulders up, and I'm going to press down. See the resistance. So, Sunupriya Master, trapezius, C-11 done. Thank you, please sit down. Can I have the next slide, please? C-11. First, just ask the patient to say something. Just say anything you feel like. Hi. Say a few words. Don't say just hi. The rain in Spain rules mainly in the plain. Hypoclosal testing. Listen to the articulation. Just articulation. Look back, look forward, look back. Now, you just see whether it is coming right or not. Next, just open your mouth, and watch the tongue in the floor of the mouth, as it is, inside too. Look for the position. Look for atrophy. Look for fasciculation. Look for anything, just in the floor of the mouth. Third step, I don't know why I'm laughing. There are two cluster of people who keep laughing. I will say it later on. OK, just look at the tongue in the floor of the mouth. Next, please protrude your tongue out. Good. Next, please move the tongue from side to side. And the last one. Too much. See, everything comes smoothly. Tongue in the floor of the mouth, tongue protruded, tongue moving from side to side. Everything moves slowly. And the last part of the test. Please push your tongue against the cheek. Keep it there. Please push your tongue against the cheek and push it there. Push. I know, he's a naughty boy. I know what he's doing. So this is the last test. Done. Please dispose to your respective stations.