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OSCE guide Lower limb neurological assessment Gait 1. Walk to the end of the ro

OSCE guide Lower limb neurological assessment Gait 1. Walk to the end of the room and back - Speed, symmetry & arm swing 2. Tandem (heel to toe) gait 3. Heel walking Romberg’s test  Stand with feet together and eyes closed  Observe for 1-2 mins  Positive if lose balance=sensory ataxia Tone 1. Leg roll - watch foot as you roll, should flop independently of leg 2. Leg lift- briskly lift leg off bed, at knee point- heel should stay in contact with bed 3. Ankle clonus: - Knee & ankle slightly flex, support leg with hand under knee - Rapidly dorsiflex and partially evert foot - >5 rhythmical beats of dorsiflexion/plantarflexion= clonus Power Use MRC muscle power scale Equipment - Tuning fork - Cotton wool - Neurotip - Tendon hammer Inspection Observe for clues around bed- mobility aid etc General appearance- posture, limb deformities  Scars  Wasting muscles  Involuntary movements  Fasciculation  Tremor Ataxic: broad-based and unsteady. As if drunk Parkinsonian: small, shuffling steps, stooped posture and reduced arm High-stepping: weakness of ankle dorsiflexion, won’t be able to walk on their heel Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk Hemiparetic: one leg held stiffly and swings round in an arc with each stride (circumduction). Spastic paraparesis: similar to above but bilateral – both are stiff and circumducting. OSCE guide Hip Flexion (L1/2) – “raise your leg off the bed and stop me from pushing it down” Extension (L5/S1) – “stop me from lifting your leg off the bed” ABduction (L4/5) – “push your legs out” ADduction (L2/3) – “squeeze your legs in Ankle Dorsiflexion (L4) – “keep your legs flat on the bed…cock your foot up towards your face…don’t let me push it down “ Plantarflexion (S1/2) – “push down like on a pedal” Inversion (L4) – “push your foot in against my hand” Eversion (L5/S1) – “push your foot out against my hand Knee Flexion (S1) – “bend your knee and stop me from straightening it” Extension (L3/4) – “kick out your leg” Big toe Extension (L5) – “don’t let me push your big toe down” Deep tendon reflexes 1. Knee jerk (L3/4) 2. Ankle jerk (L5/S1) 3. Plantar reflex (S1) - Normal= flexion of toes - Abnormal= Babinski sign (extension big toe, spread of others) Co-ordination Heel to shin test –“put your heel on your knee, run it down your shin, lift it up and repeat” - An inability to perform this test may suggest loss of motor strength, proprioception or a cerebellar disorder Sensation Demonstrate on sternum with eyes open, first 1. Light touch - Assesses dorsal/posterior columns and spinothalamic tracts - Use cotton to touch each dermatome, on both sides - Eyes closed, compare left to right 2. Pin-prick sensation - Assesses spinothalamic tracts. - Same as light touch but with sharp end of neurotip 3. Vibration - Assesses dorsal/posterior columns - Tap & place on distal phalanx of great toe - Move proximally if vibration not felt 4. Proprioception - Assesses dorsal/posterior columns - Hold distal phalanx of great toe by its sides - Demonstrate up & down with eyes open - Close eyes, say if toe is up or down - If cannot identify, try ankle > knee > hip OSCE guide Upper limb neurological assessment Power Shoulder ABduction (C5) – “Don’t let me push your shoulders down” ADduction (C6/7) – “Don’t let me pull your arms away from your sides” Wrist Extension (C6) – “Cock your wrists back and don’t let me pull them down” Flexion (C6/7) – “Point your wrists downwards and don’t let me pull them up” Elbow Flexion (C5/6) – “Don’t let me pull your arm away from you” Extension (C7) – “Don’t let me push your arm towards you” Fingers Finger extension (C7) – “Put your fingers out straight and don’t let me push them down” Finger ABduction (T1) – “Splay your fingers and don’t let me push them together” Tone - Move wrist through full range of motion - Pronate & supinate forearm (feel for any spasticity) - Flex & extend elbow - Flex/extend/abduct/adduct shoulder Note character & feel for rigidity/cogwheeling Equipment - Tuning fork - Cotton wool - Neurotip - Tendon hammer Inspection Observe for clues around bed- mobility aid etc General appearance- posture, limb deformities  Scars  Wasting muscles  Involuntary movements  Fasciculation  Tremor Face: - Hypomimia= Parkinson - Ptosis & frontal balding- myotonic dystrophy - Ptosis & ophthalmoplegia- myasthenia gravis Pronator drift - Eyes closed, arms out, palms up - Observe arm & hand for pronation Deep tendon reflex Biceps reflex (C5/6) – located in the antecubital fossa Triceps reflex (C7) – place forearm rested at 90º flexion – tap your finger overlying the triceps tendon Supinator reflex (C6) – located 4 inches proximal to base of the thumb If a reflex appears absent: make sure the patient is fully relaxed and then perform a reinforcement manoeuvre – ask the patient to clench their teeth together, whilst you hit the tendon OSCE guide Co-ordination Finger to nose test 1. Ask the patient to touch their nose with the tip of their index finger, then touch your fingertip 2. Position your finger so that the patient has to fully outstretch their arm to reach it 3. Ask them to continue to do this finger to nose motion as fast as they can 4. Repeat the test using the patient’s other hand past pointing/dysmetria= cerebellar pathology/ sensory ataxia Dysdiadochokinesia 1. Demonstrate patting the palm of your hand with the back/palm of your other hand to the patient 2. Ask the patient to mimic this rapid alternating movement 3. Encourage them to do this alternating movement as fast as they are able to 4. Repeat test using the patient’s other hand very slow/irregular) suggests cerebellar ataxia/ sensory ataxia/ Parkinsonism Sensation Demonstrate on sternum with eyes open, first Say “yes” when they feel sensation 1. Light touch - Assesses dorsal/posterior columns and spinothalamic tracts - Use cotton to touch each dermatome, on both sides - Eyes closed, compare left to right 2. Pin-prick - Assesses spinothalamic tracts. - Same as light touch but with sharp end of neurotip - If loss, test for “glove” distribution” 3. Vibration - Assesses dorsal/posterior columns - Tap & place on distal interphalangeal joint of forefinger - Move proximally if vibration not felt - (interphalangeal joint of thumb →carpometacarpal joint of thumb → elbow → shoulder) 4. Proprioception - Assesses dorsal/posterior columns - Hold distal phalanx of thumb by its sides - Demonstrate up & down with eyes open - Close eyes, say if toe is up or down - If cannot identify, try wrist > elbow > shoulder OSCE guide Cranial nerves examination Olfactory nerve- I - Any changes in sense of smell recently? - Check patency of each nostril - Eyes closed, occlude one nostril and guess smell, same with other side Optic nerve- II Inspect pupils - Size: - Shape: should be round - Symmetry: Visual acuity - 6m from Snellen chart, ensure glasses are worn (if needed) - Record as chart distance/number of line read (max 6/6) - Can use a pinhole if unable to read unaided - If cannot read even with pinhole, reduce distance to 3m then 1m - Assess if can cound number of finger you’re holding up - Assess if can see gross hand movement - Assess if can detect light from pen torch shone in eye Pupillary reflexes (in dim light) Direct: shine light in pupils and observe constriction Consensual: shine light in pupil, observe opposite pupil constrict OSCE guide Swinging light test: pupil with defective CNII dilates when light shone on it (relative afferent pupillary defect) Accommodation - Focus on far object - Place finger 15cm away, alternate looking at far & near object - Should see constriction and convergence bilaterally (when looking at close object) Colour vision: Use ishihara charts Visual field Fundoscopy Preparation 1. Darken the room. 2. The patient should ideally have their pupils dilated with short-acting mydriatic eye drops. 3. Ask the patient to fixate on a distant object. Assess for red reflex 1. Position yourself at around 30cm from the patient’s eyes. 2. Looking through the ophthalmoscope and ensure the light is directed into the pupil. Observe for a reddish/orange reflection in the pupil. An absent red reflex may indicate the presence of cataract, or in rare circumstances neuroblastoma. Move in closer and examine the eye with the ophthalmoscope 1. Find a vessel on the fundus and focus on it using the dial on the ophthalmoscope. 2. Follow the vessel along to the optic disc. If you can’t find the optic disc, stay on the same vessel and follow it the other way. 3. Assess the optic disc – colour / margin / cupping 4. Assess the retinal vessels – cotton wool spots / AV nipping / neovascularization 5. Finally, assess the macula – ask the patient to uploads/Sante/ osce-guide.pdf