Table of Contents
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