128: Cranial Nerves 6-12

Hello and welcome to the Physician Assistant Exam Review Podcast. My name is Brian Wallace and we are here with episode 128, covering the cranial nerves. My goal here is to give you more content, but at the same time, demonstrate to you the thinking and skills you can use to improve your scores and your odds of success. My goal is always to improve your odds of success wherever we can do that, whether that’s better studying, whether that’s better testing, whether that’s better management of our testing anxiety and our anxiety in general, whether that’s dealing with our ADD and finding ways around that. Anything we can do to pick up points in PA school or on the PANCE, I am all for it. That’s what I do for a living now. With that in mind, I want to make sure that you know that registration for the April cohort of the 33 Days to Pass the PANCE program begins next week and why that’s important.

Is because with this particular cohort, I am limiting the seats to 35. I am limiting the seats to 35 seats for a few reasons. One of those is that for the first time ever, I’m bringing on coaches. Previous alumni of the program who have gone on to do amazing things and do really well have raised their hand and said, hey, I really want to give back. I really want to help. I want to help students who are in the same position I was who had failed the exam once, twice, three times. I want to help students who are feeling uncomfortable, who are nervous.

I want to help students who are struggling with their EORs. And I want to give back and participate with everything that you’re doing. And I finally said, okay, let’s go ahead and do that. I think it’s going to be great. And we’re going to do that for the first time with the April cohort. So in order to make sure that everything goes really well and that I have everything kind of dialed in, I’m going to be holding it to 35 seats. So, what that means is if you’re interested in joining us for the April cohort of the 33 Days to Pass the PANCE program, then you are going to want to go today over to physicianassistantexamreview.com/33 and register for the early notification list.

Because what I’m going to do is next Monday and Tuesday, I’m going to send out an email to the people on that list and let them know that pre-registration is going to be open. And at that point, you can go ahead and register, and anyone who gets in during that two-day period, I’m not going to close them out. I know I’ve had some people who are a little nervous about that, people who really wanted to get in because they’re in dire straits and needed some help. I’m not going to close anybody out on Monday and Tuesday. However, I’m going to open it up to the general public on Wednesday, the 12th. If I don’t have 35 people at that point, I will open it to the general public. And at that point, I will close the doors as soon as we have 35 people.

So, just so you understand the situation. If you’re interested, if you want, if you’re struggling with end of rotation exams, if you are concerned about the PANCE, if you’re considered at risk, if you know someone, even more importantly, if you can help someone else out, if you know someone who falls into one of those categories, please pass it along. physicianassistantexamreview.com/33. Oh, I am actively working to upgrade the information page there. It is going to be changed a little for April because of all the things going on. There’s a lot I’m adding to the program, including some amazing bonuses and the coaches and some other things that will wind up on that sales page, but quite honestly, just haven’t been able to get to it. That’ll go up in the next couple of days.

So if you don’t see the coaches on there as one of the benefits of this particular program, then come back in a day or two and you will see the updated page with some things I think you’re really going to be excited, at least I’m really, really excited about. So again, if you’re interested, go over there to physicianassistantexamreview.com/33. This is going to be a little bit maybe of a longer show than normal because we’re going to cover six of the cranial nerves. But with that being said, I need to begin with a public service announcement. I got an email from someone today who had her email address from her school shut down without warning, without notice. And it happened because she’s a little ways out from graduation. She failed her PANCE and I’ve been working with her.

And a few months after graduation, they shut down that email address. So if you’re using your school email address as a personal email address, understand that that’s a little bit dangerous because you don’t have control over that. So if you’re using it to sign up for Amazon, sign up for Netflix, whatever else you’re using it for, I would be a little cautious about that and consider moving it either to Gmail or Yahoo or something else so that you have a portable email address. I argue with my parents all the time because they still use their Comcast email address. And God forbid, if they ever wanted to change cable companies, they would have this email address that they use for everything. So you want that to be portable. And it’s definitely an issue with people once you graduate, even if you don’t, you know, even if you pass and everything’s amazing.

If it’s the only email you ever use, you’re going to have to move everything out of there at some point regardless. So, to me, it’s just a mistake to overuse that email address. I understand why people do it, but definitely consider it. She was in a world of hurt as she was immediately just locked out of her email account and accessed everything. One of the reasons she reached out to me was because all of her products that she’d purchased through me, all of our communication was locked. She couldn’t get into anything. And that was a real hassle for her that she spent a few weeks trying to solve because her school didn’t want to let her back in because it’s not their policy.

And on and on and on. So, anyway, just a quick public service announcement. If you don’t have, if you’re only using your school email, please, please, please find another email service when you start signing up for other things and make sure that it will remain available to you as time goes by.

All right. So let’s jump into our cranial nerves and we’ll begin with our priming questions. Which cranial nerve is tested with the cover test? Which cranial nerve is tested with the cover test? A patient’s eye drifts medially at rest and cannot abduct. Which cranial nerve is affected? The patient’s eye drifts medially at rest and cannot abduct.

Which cranial nerve is affected? The patient has facial weakness that includes the forehead. Is this lesion central or peripheral? The patient has facial weakness that includes the forehead. Is this lesion central or peripheral? The patient has facial weakness… My patient has episodic vertigo, fluctuating hearing loss, and tinnitus.

What’s the most likely diagnosis? Yeah, so I made these kind of a pain. They’re a little less straightforward than normal, but I did it on purpose because I want you to see how questions may come. And it’s not just about, you know, which cranial nerve, like the first one was, which cranial nerve was tested with the cover test. Well, it’s a little bit harder, but you see medial drift. Medial drift, that should be more distinct, but not all of them are going to come that way. I’m going to run through at the beginning of this right now, just the cranial nerves 1 to 12.

We’re just going to name them and give one small thing that it does, something real simple. What I would love for you to do, what would be the most valuable thing is for you to stop for just a second and think through in your head, what were the cranial nerves? What are they? 1 to 5. And then 6, 7, 8. And then 9 and 10. And 11 and 12.

I grouped them a little bit in my head to help me remember. What were they? And then, can you think of one thing that goes with them? So, I’m going to read through it, because I’m going to cheat and look at my paper. I don’t have them memorized, but it would be an excellent idea if you beat me to each of these. So, number 1 cranial nerve 1 is olfactory for smell. Cranial nerve 2 is the optic nerve for vision.

Cranial nerve 3, remember, oculomotor for eye movement, pupil constriction, and eyelid elevation. Cranial nerve 4, it’s a trochlear nerve. It’s also for eye movement. The trigeminal nerve is next. Oh, sorry, I should have said cranial nerve 5. Facial sensation, mastication. Cranial nerve 6, abducens.

This is also for eye movement. This is the lateral movement. 7, do you remember? 7 is the facial nerve. This is for facial movement, taste of the anterior two-thirds of the tongue, lacrimation, salivation. Cranial nerve 8, vestibulocochlear nerve, hearing and balance. 9 is the glossopharyngeal nerve.

This is taste in the posterior one-third, swallowing, salivation, carotid body sinus reflex. Cranial nerve 10 is the vagus nerve, autonomic control, heart, lung, digestion, swallowing, phonation, and the gag reflex. I can’t help but think of people vasovagaling in the OR. Definitely, if you are heading into your surgical rotation, have some orange juice in the morning, have something to eat, anything is helpful. It doesn’t happen often, but it does happen. Accessory nerve is next, which is cranial nerve 11. This is the shoulder shrug, trapezius, and the head turn.

What’s the last one? What’s 12? This one should be easy. Hypoglossal. This is for tongue movement.

All right, let’s jump into these. We’ll talk a little bit. We’re going to have an overview of each one, the presentation, maybe some physical exam findings, what you’re going to be rolling out and looking for, the causes. And then we’re going to cover the treatments for each of those. I often have the common causes or risk factors or things higher up. Here I have them towards the bottom because treatment really depends directly on what the cause was. So I kind of linked those together in this section.

Don’t know if that is good or bad, but it’s what I did.

All right, cranial nerve number six, the abducens. We’re going to talk about the palsies of the cranial nerves. That’s really what this section is. So this is a dysfunction of cranial nerve six. This innervates the lateral rectus muscle. So the real key here is this is inability to abduct resulting in horizontal diplopia. So the patient cannot abduct the eye.

Cranial nerve 6 has a long intracranial course, which makes it vulnerable to increased intracranial pressure. So an elevated ICP, I said elevated ICP, that’s sort of redundant. And ICP here can be a major issue for a cranial nerve six palsy. Presentation here is horizontal diplopia. It worsens with the gaze toward the affected side. It has to do with that muscle not working, right? So, the the the eye isn’t coming laterally, so then you’re not getting the same view in each eye.

So, you get diplopia because you’re seeing differently through each eye as you look to the side. I hope that makes sense. But if you kind of move your eyes around it, to me, I’m literally looking to my right as I’m describing it, and I’m picturing that my right eye is not moving as far to the right as my left eye is moving to the right. So, then I’m getting two different images, and that causes a diplopia. I look kind of goofy. It’s why I’m not doing this show on camera. You can get some medial deviation because the muscle is unopposed medially.

So, if you’re at rest, if it was my right eye that was affected, my right eye may drift lateral, I’m sorry, not lateral, to the left because that muscle is not being opposed. You can get headaches, papilledema, and that’s also, you’re looking for signs of increased intracranial pressure. Physical exam. So we’re going to do an eye motion test, right? And we’re going to look for that limited abduction. Here we can do the cover test so the eye will drift medially, right? With the cover test, we’re going to be looking for signs of elevated intracranial pressure with papilledema, headache, and vomiting.

So what are we going to do here, right? If we have a patient who comes in with these signs, we can do an MRI if we want to rule out a tumor or a stroke or MS. We can get a CT of the head if we think that there’s increased intracranial pressure or acute trauma. We can get a lumbar puncture if we think we have increased intracranial pressure. If we think it might be giant cell arteritis, we can get ESR and CRP. So that’s kind of what we’re going to do throughout this section, right? We’re going to be looking for what we think the causes might be.

So our lab studies and imaging are going to be fairly redundant. What you need to do is just be thinking about them in relation to what you think might be causing the problem. So common causes here, increased intracranial pressure. So, although it’s rare, something that tends to be an issue with this particular problem is idiopathic intracranial hypertension, which is more something you’re looking for in a young obese female. Hydrocephalus or mass effect. You can get microvascular diseases that can cause this. So, diabetes and hypertension, skull fracture, multiple sclerosis, or a brain stem stroke.

Treatment is going to be about the underlying issues. That’s what this is going to be every single time. So, with our increased intracranial pressure, pressure shunting may be necessary, or surgery. In the case of idiopathic intracranial hypertension, weight loss is going to be on the treatment plan. Acetazolamide might help. If the patient has diabetes or hypertension, we’re going to obviously want to treat those. You can use surgery for strabismus if the problem is severe.

So the big thing here is if they have an issue where they’re looking to the side and the diplopia gets worse, you’re thinking cranial nerve six. That’s really, really the key here. And obviously the most common cause, well not obviously, but the most common cause here is increased intracranial pressure. And if they have this issue bilaterally, then you’re definitely looking at increased cranial pressure. Cranial nerve seven, facial nerve palsy. So this is a dysfunction of cranial nerve of cranial nerve seven, which controls facial expression, lacrimation, salivation, and taste, which we talked about earlier. It can be peripheral, which is something like Bell’s palsy or Ramsay Hunt, or central, like a stroke or a tumor can cause.

Remember, we talked about that briefly up in our priming questions. So see if you find it here. Unilateral facial weakness, unable to close eye, flattening of nasolabial fold. So this is pretty distinct. If you see pictures of people with Bell’s, you’ll… it’s a very distinct look they get because of that inability to close that eye completely and that flattening of the nasolabial fold. Loss of forehead movement in peripheral palsies.

Loss of forehead movement in peripheral palsies. That was one of our questions. Loss of taste, anterior two-thirds of the tongue. Loss of taste in the anterior two-thirds of the tongue. Hyperacusis. I think that’s how you pronounce it. Increase sensitivity to sound.

Decreased lacrimation if greater petrosal nerve is affected. So you can get some decrease in lacrimation. On physical exam, facial asymmetry. So this is usually one side, right? If it’s a peripheral lesion, the entire side of their face is affected in something like a Bell’s palsy. In a centralized lesion, you’re going to get a lower face affected and the forehead will not be affected. Eyelid closure testing.

So inability to close affected eye would lead you to a peripheral palsy of cranial nerve 7. You can do a taste test. And again, these patients may have a hyperacusis test and increased sensitivity to sound. Lab studies and physical exam findings, clinical diagnosis in a classic case like Bell’s. This is something you look at and should be able to recognize based off of images and seeing examples. MRI, if you are concerned about a tumor or MS or stroke. CT if you’re concerned about trauma.

You can get issues with Lyme here. So maybe something to consider. And then common causes would be things like Bell’s palsy, Ramsay Hunt syndrome, which is a varicella zoster reactivation within the ear. Sounds horrible. Stroke, Lyme disease, acoustic neuroma, and sarcoidosis. Treatment, Bell’s is going to be prednisone, 72 hours, artificial tears for eye protection. Ramsay Hunt is going to be prednisone, plus either acyclovir or valacyclovir.

Lyme is doxycycline or IV ceftriaxone if it gets worse. Stroke, we’re not going to head down the whole treatment plan there, but neurovascular evaluation and so forth. So, our takeaways here is as the forehead is involved, you’re thinking peripheral. Bell’s, Ramsay Hunt, Lyme, maybe trauma. If the forehead is spared and the forehead still moves, you’re thinking centralized issue, stroke, tumor.

All right, let’s keep working. Cranial nerve eight, vestibulocochlear nerve palsies. So this is a dysfunction of cranial nerve eight, responsible for hearing and balance. So there’s two separate parts here, this cochlear branch and the vestibular branch. So one is for hearing and one is for balance. Presents with hearing loss, tinnitus, vertigo, and balance issues. Makes sense, right?

Clinical presentation. You get sensorineural hearing loss, unilateral or bilateral, tinnitus, ringing in the ears, vertigo, room spinning, and dizziness, gait instability, people who may actually fall over, and nystagmus if there’s a vestibular component involved. Physical exam. So this is absolutely brutal. I was working with some students up at Pace, and I brought up a question on Weber. And we’re in a test and they were telling me they just did it. So they were excited to be able to answer it.

But I always feel like if I move away, I know this really well. And the second I move away from it and I blink, I forget which does which. But the Weber test lateralizes the unaffected ear. So this is for sensorineural hearing loss. The Rinne test is air conduction. So air conduction greater than bone conduction, normal or sensorineural loss. If bone conduction greater than air conduction, then conductive loss.

And it’s not a cranial nerve eight situation. This is where you might want to go back and check the notes and put something like this up on your wall on some post-it notes or something so that you’re seeing it quite frequently and you can get it to sink in. This is definitely something that’s going to be tested, definitely something you’re going to be asked. I would say high, high, high on my list would be to know the difference between these two because if you get a question on them, it’s going to be on both, right? So you’re going to need to be able to look at them and separate them. Also, for physical exam, if the patient has vertigo, you can do Dix-Hallpike maneuvers, which we don’t really learn about, but at least I didn’t. I have a good friend who’s a physical therapist who treats vertigo, so I know a little bit about some of this, but not really from my PA school.

So, this is maneuvers with the head that you move around, and you’re trying to, in this case, I think you’re trying to initiate a episode of vertigo. And that would then show that you have benign paroxysmal positional vertigo and not a cranial nerve palsy. There’s also something called the head impulse test. This is another movement where you have the, I think if I remember correctly, you have the patient watch a fixed point, then you turn their head real quick. And if they can’t hold the fixed point with their eyes, but they have to like readjust them and move them, snap them back. It’s called a corrective saccade. I’m not sure how to pronounce that.

And that would indicate a vestibular neuritis or labyrinthitis instead of a cranial nerve palsy. Again, something that you should probably go back through and review. I’m not sure you’re going to see those as questions as nearly as frequently as you’ll see the Weber and Rinne test. At least that would be my, how I would go about it. Lab studies and imaging. You can do audiometry. So this would confirm the type and severity of hearing loss, MRI with brain with contrast.

If you’re concerned about an acoustic neuroma, CT if you’re trauma or a congenital malformation, and then again you can do viral serologies if you’re worried about something like Lyme or varicella or anything along those lines. Common causes here is acoustic neuroma, gradual unilateral hearing loss, and imbalance is what they present with. Meniere’s disease is episodic vertigo, fluctuating hearing loss and tinnitus. Labyrinthitis is vertigo plus hearing loss following an upper respiratory tract infection. Vestibular neuritis, acute vertigo without hearing loss. Ototoxic drugs, aminoglycosides, cisplatin, loop diuretics, bilateral sensorineural hearing loss, and then in a stroke, you get sudden vertigo, ataxia, diplopia, and weakness.

All right, so again, as we look into our treatments, we have to look back at our causes. So there’s something like an acoustic neuroma. Well, we’re either going to watch it, or we’re going to excise it or apply radiation. If you have something like Meniere’s, low-sodium diet, diuretics, vestibular rehab. Labyrinthitis, hopefully, is self-limited, so you do supportive care. Vestibular neuritis, you do vestibular rehab, and steroids if it’s really severe. Ototoxicity, what do you do for ototoxicity?

Number one, discontinue the offending agent.

All right. Let’s talk about the cranial nerve nine and ten.

Now, these are a little bit different. We group them together because the effects are similar because the actions with the gag reflex. We’ll separate them out as we go, but I want to group them. And I think that one of the things I want you to understand is that grouping these into different categories can be helpful, right? So you can look at them from, you know, should I learn the eye movement cranial nerves together? Should I learn the, different pieces in different groups rather than just taking the list that they gave you, but thinking it through and thinking how you would recreate this list if you were to recreate it, not just from anatomical reasons, but from functional reasons. And maybe that would be a way to help it stick.

Let’s talk about these. So cranial nerve nine controls taste and swallowing in the gag reflex. Cranial nerve 10 is swallowing, phonation, autonomic functions like the heart, lungs, and GI, and the gag reflex. You can get dysphagia, voice changes, and loss of gag reflex. Clinical presentation, trouble swallowing, hoarseness is a good one. It’s one that I think you’re going to see described with cranial nerve 10. Loss of gag reflex, but the key here is it’s cranial nerve 9 is the sensory part, cranial nerve 10 is the motor part.

Uvula deviation away from the lesion. So again, I don’t think I’m going to see anything about a uvula in any other context. I don’t remember ever seeing that. Could be wrong, but anything that that talks about the uvula, I’m going to be thinking cranial nerve 10, because I really can’t think of another instance where it comes up. Shoot me an email if you think I’m wrong. If you have something, I’d love to share with everyone. Palate elevation asymmetry, and you can get syncope if it’s a vagal dysfunction.

Physical exams, we’re going to test out all those things, right? So we’re going to test our gag reflex. It’s going to be absent if there’s a cranial nerve 9 or 10 issue. We’re going to again look for that uvula moving away from the affected side. Voice quality, hoarseness, breathiness suggests a cranial nerve 10 involvement, swallow assessment for risk of aspiration. And then I’m going to be looking at my common causes. And in this case, it’s going to be strokes, Guillain-Barre if I’ve got progressive dysphagia, autonomic instability, tumors.

Neurosyphilis is rare, but interesting. Trauma, like from a surgical injury and or from a, you know, from either thyroid or neck surgery, ENT surgery, carotid dissection, those sorts of things. Treatment. If we think it’s a stroke, it’s going to be supportive care and swallow precautions. If we think it’s Guillain-Barre, it’s going to be IVIG and plasmapheresis. Tumors would be oncological management or neurosurgical. Vocal cord paralysis would be speech therapy, possible surgical intervention.

Modified diet for aspiration risk. So again, key takeaways, things you’re going to look for and how you’re going to separate these. This is the key. How are you going to separate the cranial nerves from each other? How are you going to find the questions that are about cranial nerves and pull them apart? Well, uvula deviation should always be cranial nerve 10, right? You should be easy to hold on to that.

Loss of gag reflex, cranial nerve 9 and 10. Those should be things that pop off the paper at you. Cranial nerve 11, accessory nerve palsy. This is a dysfunction of the spinal accessory nerves, which innervates the sternocleidomastoid and the trapezius muscles. These should be really easy on your list, right? Because here we get weakness in head turning from the sternocleidomastoid dysfunction. And the head will tend to turn away from the affected side because you don’t have the opposing muscles working.

You can get a shoulder droop, difficulty shrugging the shoulders against resistance, scapular winging, neck or shoulder pain. Again, this should jump off the page. So I’m looking for what makes this one distinct. This is the only cranial nerve that deals with shoulder, the only issue that is weakness with shoulder shrugging and head turning, right? You’re not going to find that in a lot of other diseases. You’re not going to find that in a rotator cuff injury. You’re not going to find that in a patient who needs a shoulder replacement.

It’s just not going to show up there. The place it’s going to show up is in a cranial nerve 11 palsy. So you’re going to have the patient rotate their head against resistance. You’re going to look for weakness. You’re going to have them shoulder shrug against resistance. You’re going to look for weakness. And then you’re going to look for that winged scapula.

This one should be really straightforward. Lab studies and imaging. MRI, cervical spine, if we’re concerned about a tumor. CT of the neck. If we think we may have an injury or trauma, we can do an EMG. The most common cause here, and this is important, is iatrogenic, which means we did it. Some sort of neck surgery, lymph node dissection, carotid endarterectomy, something along those lines, the ENT surgery, I don’t know, something in there that’s going to be a cause.

It’s going to be surgical intervention that we did. Trauma or, you know, along those same lines, whiplash or penetrating neck injuries. Then we move on to tumors or neurodegenerative diseases or very rarely idiopathic. Our treatments are going to be physical therapy, nerve repair if possible, pain management, surgical decompression if we think there’s some kind of a lesion compressing it. Again, our takeaways here, shoulder shrug, head turning. Most common cause is iatrogenic. Our last one is cranial nerve 12.

And I think about this one in a couple different ways. One of them is if I have a list like this, I tend to look at the first thing on the list and the last thing on the list. And some of those are easier for me to remember than like the sixth thing on the list. In this case, because olfactory is number one, that’s really easy, and hypoglossal is number 12, that’s kind of easy. So I’d like to break it up that way and look at those two separately and make sure I really know them. In this case, they’re very straightforward, right? The hypoglossal nerve controls the tongue.

Not a big deal. It may, if it’s not functioning correctly, you may have tongue weakness and deviation and atrophy. Clinical presentation might be the deviation toward the affected side due to the unopposed muscles like we’ve been talking about, difficulty with speech, dysphagia, tongue atrophy or fasciculations. So how do we test this? Well, physical exam, you do a tongue protrusion test. Take your tongue out. If it deviates toward the lesion, if it deviates to one side, we’re concerned about a cranial nerve 12 palsy.

We can look for atrophy. We’re going to look at their speech, lab studies and imaging. We’re going to get MRI in case we’re looking for a stroke or tumor or maybe neurodegenerative disease. What about a CT? If we’re looking for a head trauma, you can get an EMG. Common causes here would be a stroke. Guillain-Barre syndrome can cause an issue here.

Tumors, trauma, multiple sclerosis. You can see how I’m speeding these up because they’re so repetitive. So I’m speeding up some of these common causes and then the treatments because the treatments are addressing the underlying issues. So if I have a speech problem, well, I am going to do some speech therapy. I’m going to use swallow precautions. I’m going to do some physical therapy to deal with some of the muscle issues, right? And I’m going to try to build up the muscles that I have.

The key takeaway here are tongue deviation toward the lesion, tongue fasciculation or atrophy, stroke. Sorry, if you have bilateral issues here, then there’s a high risk for aspiration. That’s one of the things I wanted to point out.

Okay. We’re getting towards the end here, but something I wanted to point out to you is, and I wasn’t going to be, but it’s going to be, I just decided to make it today’s study tip. Today’s study tip is going to be an idea that I wrote about a long time ago in the Physician Assistant Exam Scholars newsletter, probably a few years ago. I haven’t written that publication in over a year. That was an absolute pleasure. That was a 16 page newsletter, a print newsletter I released every single month for five, six years. And I loved writing it because it gave me the opportunity to explore ideas about test taking, explore ideas about memory function and anxiety management and time management, all these things that help students and help me, quite frankly, dealing with ADD, dealing with all these different things.

And one issue that I wrote about, going through this section reminded me of it. And it was the idea of thinking about how you study a little bit like someone programming or coding. And it’s been a long time since I did. So please don’t crucify me for poor vocabulary here. But I did a little bit of coding after college, and I went back to school at nights to learn it. And some of the things that I think about as I’m looking at sections like this, right, is that common causes and treatments and labs and studies for each of these is pretty much the same. It’s not identical, but it’s very similar.

That’s why I get kind of bored at the and then I just start racing through them because they’re kind of the same, right? Stroke, trauma, Guillain-Barre, right? Some type of mass effect, lesion. So you want to look for the things that are part of all of them and then create almost like a reference table in your head. I’m not sure the vocabulary when it comes to programming, but what you would do is if you had a bunch of stuff like this, rather than writing out all of those extra lines of code, you would take out every time it’s duplicated and put it into a reference table, and then just write one line of code that would reference that table when you needed it. So this would, this cuts down on the amount of text in your coding and speeds up your software, right? I do the same thing when I’m studying.

What of these do I not really have to learn or can I put into a box and pull out for every single cranial nerve, right? So I can think about, let me just see if I can come across one here. Things like MS, things like tumors, things like strokes, things like trauma. That’s going to be for every single one, right?

Now, ototoxicity isn’t going to be. And neither is maybe Meniere’s disease. Maybe it is, maybe it isn’t. But you can think about them in sort of groupings. Same thing with treatments. Or I’m sorry, my lab studies and imaging. If I’m getting an MRI, I’m looking for a stroke or a tumor.

If I’m getting a head CT, I’m looking for a trauma, right? So those things can kind of all get grouped together and then referenced when you need to. You don’t have to memorize each one for each thing. And then there’s less you have to know overall or less you have to memorize overall. It’s one way I like to think about this. There’s just different approaches to studying, different approaches to retaining information. So two that I covered today is one is the fact that when I look at lists, I look at the first thing and the last thing.

The other one would be this idea of this mental reference table to pull out information. You know, another place I like to think about this, and I think the example I probably wrote about was in childhood exanthems. They’re so similar. There’s so much overlap that you can just pull out chunks of it that apply to all of them. And then you don’t really, it’s helpful that it colors in the stem of your question, but it doesn’t help you to separate out the different diseases, right? So they’re not really going to ask questions on it. They’re just going to use it for colorful information.

I hope that makes sense and I’m not making this more confusing. But I love diving into these different ways of think, different ways of study, different ways to go about things. If you find that interesting, if you find that helpful, if you haven’t spent any time thinking about your skills and the way that you approach things, you may want to consider the 33 Days to Pass the PANCE program. The next cohort’s coming up in April, if I haven’t mentioned it already. So if you’re interested or you know someone who’s struggling, you know someone who might benefit from looking at things from a little bit different perspective, from trying some different techniques, some different methods, that’s really what we do inside that program. We do not pile on more medical content. We work on developing skills, developing processes to make sure that you are your absolute best on exam day is really, really what we do.

So you can find out more about that at physicianassistantexamreview.com/33. But registration is, pre-registration is opening on Monday the 10th and open registration will happen on the Wednesday the 12th.

All right, let’s answer our priming questions and get out of here. Which cranial nerve is tested with the cover test? All the way back to the beginning. Which cranial nerve is tested with the cover test? That, my friends, would be cranial nerve six. A patient’s eye drifts medially at rest and cannot abduct. Which cranial nerve is affected?

Once again, cranial nerve six. A patient has facial weakness that includes the forehead. Is the lesion central or peripheral? Remember, we talked about this. A patient has facial weakness that includes the forehead. It’s cranial nerve seven and it is peripheral. A patient has episodic vertigo, fluctuating hearing loss, and tinnitus.

What’s the most likely diagnosis? Our diagnosis here is Meniere’s disease.

All right. This one’s been a little bit long, a little bit difficult. A section that’s clearly not my favorite, but one that I definitely think is worth learning because you’re going to get questions on it. It’s not nearly as hard as I think it is. It just needs to be set up in specific ways and approach a certain way.

All right. Well, best of luck. Take care. It was such a pleasure having you with me today. I really do appreciate you showing up each and every week and I love to have you here. So thank you so much. And I can’t wait to get back to this next week.

Take care.