128b Cranial Neves 6-12 PANCE Practice

Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 128, the companion episode. I’ve been doing these companion episodes and having a blast with them. This is where we reinforce the things that we are learning. So it’s always important to take some time to not just go over the information, but to set it into your brain to make sure you’re building out the neural networks that are going to hold it, right? We are not robots. We’re not computers.

We can’t just look at something once and have it in our heads. It doesn’t work that way. I wish it did, but at least for me, it does not. There’s things we need to do in order to make sure that we maintain that information for the long term and then we can hold it in. So what I generally do is on a normal content-driven podcast, I don’t normal is a weird word, on the content-driven podcast, I cover all the information and I try to tell stories and I try to give you some things and some tips and ways to hold it in your head. But these companion episodes are where we go a little deeper, a little bit further into the idea of practicing, right? Of practicing.

And I can’t think of what I was listening to this week, but there was something that I was listening to. And I caught myself trying to answer all the questions before the person doing the show said the answers. And it was something stupid. It wasn’t, maybe it was like a sports talk radio kind of thing, whether, I think I was listening to the Eagles radio this week, they were talking about all the players we’re losing. And I was very sad about what our defense might look like anyway. But I just caught myself reaching out mentally and saying, oh, this is the answer. Oh, this is the answer.

And that’s what I need you to be doing when you come to this podcast, when you come to these episodes, is not to be passively just listening to me. That’s kind of helpful, but not really helpful. What’s really helpful is to use your brain. Engagement is the word I’m always looking for. When I talk about active studying, it’s engagement that makes all the difference. So today we’re going to be finishing up cranial nerves. We’re going to do six to 12 today, going through those.

Hopefully you’ve been over on the Instagram page where I’ve been posting questions on cranial nerves. They’re a little tough, at least for me, but it’s a lot of fun. And I also want to just let you know that in addition to the work I’m doing on Instagram, we are also, have opened registration for the April cohort of the 33 Days to Pass the PANCE. That will be running through March 20th. Registration is now open. There are limited seats for that class because I am bringing in so many new things, so much new and exciting and fun bonuses. And most importantly, the coaches I’m bringing in.

So I’m bringing in previous alumni who have graduated from the program, have graduated from their PA programs, have gone on from struggling on EORs. Some of them have struggling on the PANCE. Some of them are failing it more than once. But who have gone through the 33 Days program and come out the other side incredibly successful and they just wanted to give back so much. I hear from people all the time who are like, how can I help? What can I do? So I’m going to bring them back, a small group of them, into this April cohort and have them run small groups with with the students so we can do a much more hands-on approach to what we do inside of that program.

I think it’s going to be fantastic and really help people who are looking for a little structure, are looking to develop their skills and how they learn, and how they take tests and get some immediate feedback on that stuff. It’s going to be really, really exciting. And if you’re interested or you know someone who’s struggling on an end-of-rotation exam, you know someone struggling in school, you know someone who, God forbid, hasn’t passed their PANCE, please, please, please, physicianassistantexamreview.com/33. That’ll be open through the 20th, provided we don’t hit the max on our number of students. Like I said, I am keeping that a little bit tight this time. The next cohort will be in June, and I’m running them pretty much every other month from here on out. So you can kind of work from there if your PANCE is coming up.

Although I do sort of recommend that you take this, go through this program a little bit before your PANCE. It’s definitely helpful for end-of-rotation exams and end-of-curriculum exams. So it gives you some time to practice the material after you learn it. So it’s kind of a, it doesn’t need to be right before your exam is what I’m trying to say. Anyway, let’s jump into cranial nerves and get a move on. So one more time, maybe for the last time in a long time, I’m going to just run through quickly. Cranial nerves 1 to 12.

We’re going to name them. Then we’re going to give a short piece on what they are. And I want you just ahead of me, just ahead of me to be thinking, okay, cranial nerve 1. And then what’s its name? And what does it do? So as I go through them, I want you to be in front of me, not behind me, waiting for me to say it. It’s almost like when I’m in the OR, right?

I’m not waiting for the surgeon to direct me, I’m moving in front of them. I’m sort of thinking about where they’re going to move next and how I can help the most and I’m moving to that spot. So here we go. Cranial nerves in order. Number one is the olfactory nerve responsible for smell. Number two is the optic nerve responsible for vision. Number three is the oculomotor nerve, eye movements, pupil constriction, eyelid elevation.

Number four is the trochlear nerve, eye movement. So this is the superior oblique muscle. Trigeminal nerve is next. Sorry, I didn’t read that in the right order to help you out. But what’s it for? Facial sensation and mastication. Cranial nerve number six is abducens, lateral eye movement.

Number seven is the facial nerve, facial movement, anterior two-thirds of the tongue is for taste, lacrimation, salivation. Number eight, vestibulocochlear nerve, cranial nerve eight is for hearing and balance. The glossopharyngeal nerve is next. Sorry, I did it again. It’s number nine. You probably knew that one too, so that’s frustrating. I apologize.

Taste, posterior one-third of the tongue, swallowing, salivation, and the carotid body sinus reflex. Number 10 is the vagus nerve. This is autonomic control of the heart, lungs, and digestion, swallowing, phonation, and the gag reflex. What about number 11? This is the accessory nerve. This says shoulder shrugs and head turns, trapezius, and sternocleidomastoid. That’s just fun to say.

Number 12 is the hypoglossal nerve, tongue movement.

All right, now that we have those taken care of, one of the things I was thinking about is how would I study this, right? What would I do? Knowing everything I know now, knowing all the techniques and things that I’ve been working on, how would I, what are some things I would do, right? So first of all, I’d want to do something active. I’d want to be engaged, like I said before. So one way to do that is to look at these. And like I said last week, when I talked about how I’d learn them in different groups and I’d move things around.

Well, that’s exactly what I did this week, right? So I took them and I was like, okay, maybe if I make my own groups, right? Not what the books tell me what the groups are, but I create my own groups and I study them my own way. So I’m rearranging the material, I’m working with the material. And that way I can retain what the things are. So rather than just learning them in order, like with a mnemonic, right? And just rolling through them and having a memorized list that I’m struggling to remember.

What if I remembered all, and I started with these groupings, where it was just the cranial nerves that dealt with eye movement? Or it’s just the cranial nerves that dealt with tongue movement? Or it was just the cranial nerves that dealt with either the face or some sort of muscle movement? These are the categories that I came up with. What about the ones that just involve swallowing and speech? What about those for sensory perception only? What about…

I think that was it. That was that was the the groupings I came up with. So, when you do things like this, it forces your brain to work with the material. I talk about doing the work a lot, and sometimes I feel like people aren’t sure what I’m talking about, and they think they’re doing the work. I find this a lot with my my children here at home. I have one who studies a lot. And he’ll study two or three hours at the table in middle school.

And he’s smart. And I’ll sit with him and I’ll watch what he does. And it’s hard for me to explain to him, but he’s doing a ton of work. He’s putting in a lot of time, but he’s not doing the work. He’s doing things that aren’t going to make it stick, that aren’t going to be helpful. So it’s important to dial in and do the things that are going to help the most. And although you may be working really hard, if you’re questioning, why aren’t I getting the scores that I want for all the time I’m putting in?

Understand it’s not about time, right? Time is not really a factor here. I was just listening to an old recording of Jim Rohn, who I love, and he was talking about the idea of, you know, wages and what you get paid and how one of the biggest misconceptions is that you get paid for time. You don’t get paid for time. You get paid for value. And how that was one of the basic facts of economics is that you get paid for value. So you get paid more per unit of time if you are more valuable as the marketplace sees it.

Right? So time is not really a factor, although we tend to use time because it’s easy to measure to think of it like it’s a factor, but it’s not, it’s not the most important thing. It’s the value in that time.

All right, so if I’m thinking about remembering these cranial nerves. Grouping them this way might help. You don’t have to do it my way. Maybe you could come up with another way. In fact, it’d be better if you came up with another way. But let’s run through them this way. So you just think for a minute as you’re driving in your car, as you’re running down the street, as you’re going for your walk, as you’re washing your dishes, whatever you do while you listen to the show, think for a minute.

Cranial nerves controlling the eye movement. There are three of them. What are they? Three nerves that control eye movement. But we have cranial nerve three, the oculomotor nerve. We have cranial nerve four, the trochlear nerve. And we have cranial nerve six, the abducens nerve.

What about tongue movement? What three? Well, maybe not three. Two. I may have done this poorly. I think it’s really down to just one. It might be just that this category I wrote, and I’m not realizing it, is related to the tongue.

I think that’s actually what it is. Let me just check.

Okay, yeah. So what are the ones that affect the tongue? Well, they would be the hypoglossal nerve is for tongue movement, right? And then you have the glossopharyngeal nerve is the posterior one-third for taste. And the facial nerve is the anterior two-thirds for taste, right? So those would be the three that affect the tongue. What about if we talk about muscle movements or facial movements?

Well, if I say muscle movements, you’re probably thinking accessory nerve, cranial nerve 11, right, for shoulder shrugs and head turns. But then you get the trigeminal nerve for mastication and the facial nerve for facial expressions. How about those involved in swallowing and speech? Swallowing and speech. Well, the easy ones there are going to be the glossopharyngeal nerve, cranial nerve 9, and cranial nerve 10, the vagus nerve. But then you’re also going to have the hypoglossal nerve for tongue movement. That’s one’s a little sneaky, but I think you get the idea.

How about for just sensory perception? Well, that’s going to be cranial nerve 1 for smell, 2 for vision, and 8 for vestibulocochlear. It took me a minute to look at the Roman numerals for 8 and realize that’s what it was. That was what the pause was there.

All right. You also have the glossopharyngeal nerve for taste and the facial nerve for taste.

Perfect. I hope you understand what I’m trying to do here. So I’m not sure if I nailed that perfectly, but the idea is really important. It’s the idea of how do you rework the material, work with it, move it around, regroup it, shift it around so that it looks like something different, but in a way that maybe you’ll retain because maybe the order that the author of the books put together doesn’t help you. Maybe the guy put all the symptoms together. It doesn’t help you the way you think. Take some time.

See if there’s a better way for you. You don’t have to reinvent the wheel on everything, but especially things like this where it’s just a list and it’s hard to retain. Definitely take some time to go over it. And to me, I don’t know. I just don’t love mnemonics for stuff like this. I understand why they are popular, why people like them, why they feel good in the moment. But I think it’s just that.

I think they make you feel good. I think they make you feel comfortable. It’s almost like using floaties instead of learning to swim. Right? The floaties don’t actually teach a kid how to swim. They just keep them up in the water so they don’t drown, which maybe that’s what you’re shooting for, and that’s okay. But if we’re looking to get past that, if we’re looking for true understanding, if we’re looking for true mastery, if we really want to score high, we have to move beyond the floaties, right?

We have to move beyond the mnemonics, even though they make us feel good. They make us feel like we’re swimming. We’re not. And that’s really why I don’t, I don’t love them. And I think there’s, you know, I’m in a minority there for sure. But I think doing the work like this and rearranging it and doing things to activate your brain and hold on to it and understand it are going to be much more valuable to you as time goes by.

All right, let’s run through some quick questions. Based off everything we’ve done so far on these cranial nerves, we’re just sticking to a six to 12 here to make things easy. I didn’t branch out into all of them. So we’re just going to do some quick questions just like what’s in The Final Step are the priming questions. And here we go. What is the primary function of the abducens nerve? What’s the primary function of the abducens nerve?

A patient presents with unilateral facial weakness, inability to close the eye, and loss of forehead movement. What’s the most likely diagnosis? What test helps differentiate between sensorineural and conductive hearing loss in a patient with suspected cranial nerve 8 dysfunction? That’s easier than it sounds. What test helps differentiate between sensorineural and conductive hearing loss in a patient with suspected cranial nerve 8 dysfunction? A patient’s uvula deviates to the right when they say, ah, which cranial nerve is affected and on which side? And the last one is tongue deviation toward the right suggests a lesion in which cranial nerve and on which side?

All right, let’s run through the answers. What’s the primary function of the abducens nerve? Lateral eye movement. The patient presents with unilateral facial weakness, inability to close the eye, and loss of forehead movement. And what’s the most likely diagnosis? Bell’s palsy. Cranial nerve seven.

What test helps differentiate between sensorineural and conductive hearing loss in a patient with suspected cranial nerve eight dysfunction? That’s Weber and Rinne test. A patient’s uvula deviates to the right when they say, ah, which cranial nerve is affected and on which side? Cranial nerve 10, the vagus nerve, and it’s on the left side. Tongue deviation toward the right suggests a lesion of which cranial nerve and on which side? That would be cranial nerve 12, the hypoglossal nerve, right? Tongue movement and it would be toward the right side.

I’m sorry, it would be a right side lesion, which would be toward the right.

Okay. Let’s run through some questions that are just going to be straightforward and based off of those facts. I want you to see how the foundation gets laid with learning those facts. And then we move forward into PANCE type questions based on those. And these aren’t super hard necessarily, but I want you to understand how the information stacks. A 45-year-old man reports difficulty seeing clearly when looking to his right. He says objects appear to overlap, and he sometimes has to turn his head to focus better.

On exam, his right eye does not move past the midline when attempting to look to the right, but all other extraocular movements are intact. Which cranial nerve is most likely affected? Oculomotor nerve, trochlear nerve, abducens nerve, or the optic nerve? Well, you should be able to remove the optic nerve right away, right? That one doesn’t make any sense. The other ones are at least having motion, but you also know that the oculomotor nerve is going to control more things in more directions, right? So I’m not going to think it’s just one.

And in the end, the answer here is C, because the abducens controls the lateral motion, right? So that’s where you get that diplopia, especially with lateral eye movement. Looking to the side.

All right, let’s do the next one. A 32-year-old woman develops a sudden onset of right-sided facial weakness. She is unable to raise her right eyebrow, close her right eye completely, or smile symmetrically. She denies limb weakness or sensory loss. There are no vesicles in her ear. What’s the most appropriate initial treatment? Prednisone within 72 hours, acyclovir and prednisone, MRI of the brain, IV ceftriaxone.

So first, what do you think it is? This is again just an extension of one of the priming questions we just did. Well the answer is it’s Bell’s palsy, right? The diagnosis. So then how do we treat that? Well it’s prednisone within 72 hours. We wanted to start steroids early here.

A 55 year old man complains of progressive hearing loss in his left ear over the past several months. He also noted occasional imbalances but denies vertigo or tinnitus. A Weber test lateralizes to the right ear, and a Rinne test shows air conduction greater than bone conduction bilaterally. What’s the most likely diagnosis? Meniere’s disease, vestibular neuritis, acoustic neuroma, or otosclerosis. I hated Weber and Rinne when I was in school. It’s not that hard.

It’s just I struggle to retain it.

All right. The answer is C, acoustic neuroma. A unilateral sensorineural hearing loss with imbalance is classic for an acoustic neuroma. The slow progression and the lack of vertigo also kind of indicate that it’s a tumor rather than something acute.

All right. Let’s try another one. Now we’re going to move on a little bit to just away from those initial priming questions and just out into the world. A 63 year old man presents with difficulty swallowing and changes in the voice over the past month. He describes his voice as hoarse and states that he occasionally chokes on liquids. On examination, his uvula deviates to the right when he says ah. Which of the following findings will most likely be present?

Deviation of the tongue to the right, loss of the gag reflex on the left, weakness of the right trapezius muscle, increased deep tendon reflexes on the left. So first you have to recognize this is a cranial nerve problem, right? So if you do that, then you can get rid of D. As long as you don’t think it… Well, I’m not going to go down that road just yet. C is a trapezius problem, right? Well, this is going to be the accessory muscle, which isn’t going to have anything to do with what we’re doing.

So now you’re down to two, right? So that’s really cool. I only have A or B left. It’s definitely one of the top questions I get is how do I decide when I get down to two like this? And here I’m going to tease you just a little bit. I have a full lesson on that within the 33 Days program. I can’t just explain it really fast here.

It doesn’t work that way. Something you have to spend a little bit more time in. It’s really powerful and works really well, but it is literally an entire lesson for the 33 Days students. In this case, your answer is going to be B, loss of the gag reflex on the left is correct. The glossopharyngeal nerve provides sensory innervation to the gag reflex while the vagus nerve controls the motor response. So that’s what we’re looking for there.

Fantastic. All right, let’s do one more, and then we’ll wrap it up for today and wrap it up with cranial nerves. A 50-year-old woman presents with progressive difficulty speaking and swallowing over the past two months. She reports occasional choking on liquids and slurred speech. On exam, her tongue exhibits atrophy and fasciculations and deviates to the right when protruded. Reflexes in her upper and lower extremities are brisk, and she has mild weakness in her right hand. Which of the following is the most appropriate next step?

MRI of the brainstem to evaluate for a stroke. EMG and nerve conduction studies. High-dose corticosteroids. Lumbar puncture for CSF analysis. Your answer here is going to be B. Electromyography and nerve conduction studies, EMGs. This patient presents with progressive bulbar dysfunction, cranial nerve 9, 10, and 12 involvement, tongue fasciculations, upper motor neuron findings is highly suggestive of ALS, amyotrophic lateral sclerosis.

EMG and NCS are the best next steps for confirming this diagnosis. It was a tougher one. That’s why we ended with that one. The goal for me, though, in these companion episodes is just to show you the way that we can progress. Right? I look at I look at studying as building blocks, right? As Legos.

I start with the basic blocks, and I try to really understand the key basic foundational blocks. And then I start putting those together in different manners in different ways. And I start trying to understand and and see how questions are going to be written and how they come. And again, I hate to harp on this, but that’s exactly what we do inside the 33 Days program, is we teach how to go through questions, how to study so that you can build out the information for this specific exam. Learn how the test questions are written so that you can study specifically for them. Build that foundation out and then see it come to life in front of you on the exam. So that the questions become, I’m not going to say routine, but they become more obvious how they’re going to show, how they’re going to be written, that sort of thing.

Anyway, that’ll wrap us up for the episode 128 companion episode. I’m so glad that you are here. I get an absolute blast out of spending this time with you and being able to work with students and be able to study with you. If you want to go deeper, if you want to go much further and see the scores that you know that you deserve, despite all the work you’re putting in, definitely join us for the April cohort of the Physician Assistant Exam Review. I’m sorry, of the 33 Days to Pass the PANCE program. You can find out more at physicianassistantexamreview.com/33. Registration is open until the 20th as long as we don’t fill up before that.

This cohort just definitely has a limited number of students available to it so we may close before that. We’ll see what happens but if you’re interested or you have know someone who’s struggling please definitely send them over there.

All right that’s it for tonight. Take care and I look forward to seeing you guys again next week when we are no longer doing cranial nerves.