NB: the OSCE instructions may be non-specific, for example: ‘Examine this patient with a tremor’, ‘Examine this patient’s gait and then proceed,’ or ‘Examine this patient neurologically’. Approach this situation by first asking a few generic questions (if allowed) or by inspecting for tremor/gait abnormalities. Then proceed with the relevant focussed examination to elicit other signs.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent

General observations

• General inspection: patient, around bed (mobility aids etc.)
• Tremor: note any obvious tremor (if none, ask the patient to close their eyes and count down from 20 to distract them)
  • Asymmetrical resting pill-rolling tremor (4-8 Hz) 
  • Begins distally (fingers, hands, forearms), can involve chin and mouth 
  • Reduced with finger to nose testing 
  • Accentuated by distraction
• Gait: ask patient to walk up and down the room
  • Shuffling (reduced stride length) 
  • Hesitant (difficulty initiating and turning (multiple steps))
  • Festinating (patient walks faster and faster so as to not fall over) 
  • Lack of arm swing (early sign due to increased tone) 
  • Unsteadiness (propulsion/retropulsion – tendency to fall forward or backward)
• Posture: observe posture while walking (stooped)

Now work down the body:

Face

• Facial inspection (hypomimia, decreased blinking, drooling)
• Glabella tap test (Myerson’s sign = blinking fails to cease with continued tapping)
• Speech: ask the patient to say a sentence, e.g. describe the room they are in (hypophonia, slow thinking, soft faint voice)

Focussed upper limbs

• Tone: increased tone can be accentuated with distraction by asking patient to move contralateral arm up and down (lead pipe = increased tone; cogwheel rigidity = tremor superimposed on increased tone)
• Bradykinesia
  • Open and close thumb and index finger like a ‘snapper’ as fast as possible (lack or decay of amplitude; slow and asynchronous)
  • Play imaginary piano (slow)
  • Open and close big imaginary doorknob (difficulty pronating and supinating)

Focussed lower limbs

• Bradykinesia: heel tap (lack or decay of amplitude; slow and asynchronous)

Extras

• Function: test undoing buttons, assess writing for micrographia
• Exclude Parkinson-plus syndromes
  • Vertical eye movements (vertical limitation = progressive supranuclear palsy)
  • Horizontal eye movements (nystagmus = multisystem atrophy)

To complete

• Thank patient 
• ‘To complete my exam, I would look for cerebellar signs (multisystem atrophy), check postural blood pressure (significant drop may be present in multisystem atrophy) and undertake a mini-mental state exam (Lewy body dementia). I would also review any drug charts (parkinsonism drugs).’
• Summarise and suggest further investigations you would consider after a full history

Here are some questions