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)
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
‘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