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.
Ask Patient’s name, DOB and what they like to be called
Explain examination and obtain consent
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)
‘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
Please list some causes of Parkinsonism
What are the Parkinson-plus syndromes?
What is the Parkinson’s disease tetrad?
List some clinical features of Parkinson’s disease
Which common class of drugs may cause drug-induced parkinsonism?
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