OSCE guide

Lower limb neurological assessment

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

Gait Ataxic: broad-based and unsteady. As if drunk

Parkinsonian: small, shuffling steps, stooped posture and
1. Walk to the end of the room and back reduced arm
- Speed, symmetry & arm swing
2. Tandem (heel to toe) gait High-stepping: weakness of ankle dorsiflexion, won’t be able to
walk on their heel
3. Heel walking
Waddling gait: shoulders sway from side to side, legs lifted off
Romberg’s test ground with the aid of tilting the trunk

 Stand with feet together and eyes closed Hemiparetic: one leg held stiffly and swings round in an arc
with each stride (circumduction).
 Observe for 1-2 mins
 Positive if lose balance=sensory ataxia Spastic paraparesis: similar to above but bilateral – both are stiff
and circumducting.
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
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Hip Ankle
Flexion (L1/2) – “raise your leg off the Dorsiflexion (L4) – “keep your legs flat on the
bed and stop me from pushing it down” bed…cock your foot up towards your face…don’t let
me push it down “
Extension (L5/S1) – “stop me
from lifting your leg off the bed” Plantarflexion (S1/2) – “push down like on a
pedal”
ABduction (L4/5) – “push your legs out”
Inversion (L4) – “push your foot in against my
ADduction (L2/3)  – “squeeze your legs in hand”

Eversion (L5/S1) – “push your foot out against my

hand

Knee Big toe

Flexion (S1) – “bend your knee and stop Extension (L5) – “don’t let me push your big toe
me from straightening it” down”

Extension (L3/4) – “kick out your leg”

Deep tendon reflexes Sensation

1. Knee jerk (L3/4) Demonstrate on sternum with eyes open, first
2. Ankle jerk (L5/S1) 1. Light touch
- Assesses dorsal/posterior columns and spinothalamic
3. Plantar reflex (S1)
tracts
- Normal= flexion of toes - Use cotton to touch each dermatome, on both sides
- Abnormal= Babinski sign - Eyes closed, compare left to right
(extension big toe, spread of others) 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
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
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Equipment

- Tuning fork - CottonUpper

wool limb neurological assessment
- Neurotip - Tendon hammer
Tone
Inspection
- Move wrist through full range of motion
Observe for clues around bed- mobility aid etc - Pronate & supinate forearm (feel for any spasticity)
General appearance- posture, limb deformities - Flex & extend elbow
- Flex/extend/abduct/adduct shoulder
 Scars
 Wasting muscles Note character & feel for rigidity/cogwheeling
 Involuntary movements
 Fasciculation Deep tendon reflex
 Tremor
Biceps reflex (C5/6) – located in the antecubital fossa
Face:
Triceps reflex (C7) – place forearm rested at 90º flexion – tap
- Hypomimia= Parkinson your finger overlying the triceps tendon
- Ptosis & frontal balding- myotonic dystrophy
- Ptosis & ophthalmoplegia- myasthenia gravis Supinator reflex (C6) – located 4 inches proximal to base of
the thumb
Pronator drift
If a reflex appears absent: make sure the patient is fully relaxed
- Eyes closed, arms out, palms up and then perform a reinforcement manoeuvre – ask the patient
- Observe arm & hand for pronation to clench their teeth together, whilst you hit the tendon

Power
Shoulder Wrist
ABduction (C5) – “Don’t let me push your Extension (C6) – “Cock your wrists back and don’t
shoulders down” let me pull them down”

ADduction  (C6/7) – “Don’t let me pull Flexion (C6/7) – “Point your wrists downwards and
your arms away from your sides” don’t let me pull them up”

Elbow Fingers
Flexion (C5/6) – “Don’t let me pull your Finger extension (C7) – “Put your fingers out
arm away from you” straight and don’t let me push them down”

Extension (C7) – “Don’t let me push your Finger ABduction (T1) – “Splay your fingers and
arm towards you” don’t let me push them together”
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Sensation Co-ordination
Demonstrate on sternum with eyes open, first Finger to nose test
Say “yes” when they feel sensation 1. Ask the patient to touch their nose with the tip
of their index finger, then touch your fingertip
1. Light touch
2. Position your finger so that the patient has to
- Assesses dorsal/posterior columns and spinothalamic
fully outstretch their arm to reach it
tracts
3. Ask them to continue to do this finger to nose
- Use cotton to touch each dermatome, on both sides
motion as fast as they can
- Eyes closed, compare left to right
4. Repeat the test using the patient’s other hand
2. Pin-prick
- Assesses spinothalamic tracts. past pointing/dysmetria= cerebellar pathology/ sensory ataxia
- Same as light touch but with sharp end of neurotip
Dysdiadochokinesia
- If loss, test for “glove” distribution”
3. Vibration 1. Demonstrate patting the palm of your hand with the
- Assesses dorsal/posterior columns back/palm of your other hand to the patient
- Tap & place on distal interphalangeal joint of forefinger
2. Ask  the patient to mimic this rapid alternating
- Move proximally if vibration not felt - (interphalangeal
joint of thumb →carpometacarpal joint of thumb → elbow → movement
shoulder)
3. Encourage them to do this alternating movement as
4. Proprioception fast as they are able to
- Assesses dorsal/posterior columns
- Hold distal phalanx of thumb by its sides 4. Repeat test using the patient’s other hand
- Demonstrate up & down with eyes open very slow/irregular) suggests cerebellar ataxia/ sensory ataxia/
- Close eyes, say if toe is up or down Parkinsonism
- If cannot identify, try wrist > elbow > shoulder
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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

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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 look directly into the light – Drusen noted in
macular degeneration

Oculomotor, Trochlear & Abducens nerves - III, IV, VI

Ptosis
Note any evidence of ptosis:
 Oculomotor nerve pathology
 Horner’s syndrome
 Neuromuscular pathology (e.g myasthenia)
 Congenital
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 Age-related
Eye movement
1. Hold your finger about 30cm directly in front of the patient’s eyes and ask them to look at it. Look
at the eyes in the primary position for any deviation or abnormal movements.
2. Ask the patient to keep their head still and follow your finger with their eyes.
3. Ask the patient to report any double vision.
4. Move your finger through the various axes of eye movement (“H” shape).
5. Observe for restriction of eye movement and note any nystagmus.
Cover test
This tests for a manifest strabismus/squint.
1. Ask patient to focus on a target (e.g. your pen top).
2. Cover one of the patient’s eyes.
3. Observe the uncovered eye for movement:
 No movement = normal response
 Eye moves temporally = convergent squint  (esotropia)
 Eye moves nasally = divergent squint  (exotropia)
4. Repeat the cover test on the other eye.

Trigeminal nerve – V
Sensory
Assess light touch and pinprick sensation:
 Forehead – ophthalmic branch (V1)
 Cheek –  maxillary branch (V2)
 Jaw – mandibular branch (V3)
Compare left to right for each branch.
Demonstrate sensation on patient’s sternum first, to ensure they understand what it should feel like.
 Motor
1. Ask the patient to clench their teeth whilst you feel the bulk of masseter and temporalis
bilaterally.
2. Ask the patient to open their mouth whilst you apply resistance under the jaw – note any
deviation (jaw will deviate to side of lesion)
Reflexes
Jaw jerk (afferent CN V, efferent CN V):
 Ask patient to open mouth loosely
 Place your finger horizontally across the chin
 Tap your finger with a tendon hammer
 Normal = slight closure of the jaw
 Abnormal = brisk complete closure of the jaw – UMN lesion
Corneal reflex (afferent CN V, efferent CN VII):
 Explain procedure and gain consent
 Depress lower eyelid
 Ask patient to look upwards
 Touch edge of cornea using a wisp of cotton wool
 Normal response = Direct and consensual blinking

Facial nerve – VII

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Inspect the patient’s face at rest for asymmetry:

 Forehead wrinkles 
 Nasolabial folds
 Angles of the mouth
 Ask the patient to perform specific facial movements
Raised eyebrows – “raise your eyebrows as if you’re  surprised” –  note asymmetry
Closed eyes –  “scrunch up your eyes and don’t let me open them” –  assess power
Blown out cheeks – “blow out your cheeks and don’t let me deflate them” –  assess power
Smiling  – “can you do a big smile for me?” – note asymmetry 
Pursed lips – “can you attempt to whistle for me?” –  note asymmetry
Closed lips – “close your lips tight and don’t let me open them” – check each side, assess power

Other things to check…

Inspect external auditory meatus (EAM) –  herpes zoster lesions  – Ramsay Hunt syndrome
Any hearing changes?  – facial nerve supplies stapedius – paralysis results in hyperacusis
Any taste changes? –  supplies taste sensation to the anterior two-thirds of the tongue

Vestibulocochlear nerve – VIII

Gross hearing testing

Ask the patient if they have noticed a change in their hearing recently.
Assess each ear individually, standing behind the patient.
1. Explain to the patient that you’re going to say a word or number and you’d like them to repeat it
back to you.
2. With your mouth approximately 15cm from the ear, whisper a number or word.
3. Mask the ear not being tested by rubbing the tragus.
4. Ask the patient to repeat the number or word back to you.
5. If the patient repeats the correct word or number, repeat the test at an arm’s length from the ear
(normal hearing allows whispers to be  perceived  at 60cm).
6. Assess the other ear in the same way.

Rinne’s test

1. Tap a 512 Hz tuning fork and place its base on the mastoid process

2. Ask the patient if they are able to hear it (bone conduction)

3. If they are able to hear it, ask them to let you know when they can no longer hear it

4. Once the patient is unable to hear the sound via the mastoid process move the tuning fork to
approximately 1 inch from the external auditory meatus

5. Ask the patient if they are able to hear the tuning fork (this is air conduction)

6. If the patient is able to hear the tuning fork via air conduction (after they were no longer able to
hear via bone conduction) it suggests their air conduction is better than bone conduction (Rinne’s
positive).
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Summary of Rinne’s test results:

 Normal = Air conduction > Bone conduction (Confusingly termed “Rinne’s positive”, despite
it being the normal result. It is probably best to avoid this term and just describe the result)
 Neural deafness = Air conduction > Bone conduction (both air and bone conduction reduced
equally)
 Conductive deafness = Bone conduction > Air conduction  (“Rinne’s negative” – again best
to avoid this term and describe the result)

Weber’s test

1. Tap a 512 Hz tuning fork and place in the midline of the forehead

2. Ask the patient where they can hear the sound:

 Normal – sound is heard equally in both ears

 Neural deafness – sound is heard louder on the side of the intact ear
 Conductive deafness – sound is heard louder on the side of the affected ear

Vestibular testing – “Unterberger” or “Turning test”

Ask patient to march on the spot with arms outstretched and eyes closed:

 Normal – patient remains in the same position

 Vestibular lesion – patient will turn towards the side of the lesion

Vestibular testing – “Head thrust test” or “Vestibular-Ocular Reflex (VOR)”

1. Sit facing the patient.

2. Ask if they have any neck pain and ask permission to turn their head very quickly.

3. Ask them to fixate on your nose. Hold their head in your hands (one hand covering each ear) and
rotate it very rapidly to the left, at a medium amplitude.

4. Repeat to the right.

The normal response is that fixation is maintained. In a patient with loss of vestibular function on one side, the
eyes will first move in the direction of the head (losing fixation), before a corrective refixation saccade occurs
towards your nose.

Glossopharyngeal and Vagus nerves - IX & X

Assess soft palate and uvula:

 Symmetry – note any obvious deviation of the uvula

 Ask patient to say “ahhhh” – observe uvula moving upwards – any deviation?  (deviation
away from side of lesion)

Gag reflex (afferent IX, efferent X) 

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Ask patient to cough– damage to nerves IX and X can result in a bovine cough

Swallow – ask patient to take a sip of water – note any coughing / delayed swallow

Accessory nerve - XI
Ask patient to shrug shoulders and resist you pushing down – trapezius 

Ask patient to turn head to one side and resist you pushing it to the other – sternocleidomastoid

Hypoglossal nerve - XII

- Inspect tongue for wasting and fasciculations at rest (minor fasciculations can be
normal)
- Ask patient to protrude tongue – any deviation? (deviates towards side of lesion)
- Place your finger on the patient’s cheek and ask to push their tongue against it
– assess power

Peripheral vascular system examination

Upper body
General inspection
Inspection
- Note if they appear comfortable at rest
- Skin colour - Note scars
- Tar staining - Cyanosis/pallor/jaundice
- Tendon xanthomas
- Gangrene
Abdomen
Palpation
Aorta
I. Temperature
 Compare temperature of limbs - Inspect abdomen for obvious pulsations
 Cold/pale= poor arterial suply - Palpate both side for expansion
II. Capillary refill time - Auscultate for bruits, above umbilicus

Pulses Renal bruits

 Radial: assess rate & rhythm, radio-radial Auscultate just above umbilicus, lateral to midline on both side
delay Renal bruit= renal artery stenosis
 Brachial: assess volume & character
 Carotid: auscultate for bruit, do not
palpate if present
 Blood pressure in both arms
Lower limbs
Inspection

- Scars
- Hair loss – PVD Sensation
- Discolouration To assess limb paraesthesia a symptom of acute limb ischaemia
- Pallor
- Missing limb - Light touch: if reduced identify extent
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Cardiovascular examination
General inspection
- Malar flush
- Inspect chest
- Inspect legs

Hands
Palms facing down

Splinter haemorrhages- bacterial endocarditis

Finger clubbing: look for Schamroth’s window

- Causes: infective endocarditis/cyanotic congenital heart disease

Palms facing up

1. Temperature: cool peripheries= poor cardiac output/hypovolaemia

2. Colour: bluish, yellowish, redness
3. Sweaty/clammy: acute coronary syndrome
4. Janeway lesions: non tender maculopapular erythematous pulp lesions= bacterial
endocarditis
5. Osler’s nodes: tender red nodules on fingers= infective endocarditis
6. Tar staining: smoker = risk factor for CVD
7. Xanthomata: raise yellow lesions = hyperlipidaemia
8. Capillary refill time: <2mins

Pulses
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1. Radial
2. Radio-radial delay: palpate both radial at same time- subclavian stenosis/aortic dissection
3. Collapsing pulse: (aortic regurgitation)
- Palpate radial pulse with hand wrapped around wrist, raise arm above head
- Feel for tapping impulse through muscle bulk= water hammer pulse (physiological
state/cardiac lesion/ high output sates)
4. Brachial
5. Carotid: auscultate, assess character and volume
6. Blood pressure

Jugular venous pressure

- Position Normovolemic patient at 45o

Hepatojugular reflux:

 Apply pressure to the liver, Observe the JVP for a rise

 In healthy , rise last no longer than 1-2 cardiac cycles

 sustained 4+ cm = positive result

 A positive hepatojugular reflux sign = right-sided heart

failure and/or tricuspid regurgitation
Face
 Conjunctival pallor – anaemia
 Corneal arcus – yellowish/grey ring around iris
 Xanthelasma – yellow raised lesions around eye
 Central cyanosis- bluish discoloration of lips/tongue
 Angular stomatitis- inflammation of corner of the eye
 High arched palate – Marfan syndrome, ↑ risk of aortic aneurysm/dissection
 Dental hygiene - source of infective endocarditis

Chest
Close inspection
Scars: thoracotomy, sternotomy, clavicular, left mid--axillary

Deformities:

Visible pulsations: forceful apex beat (hypertension/ventricular hypertrophy)

Palpation
1. Apex beat (PMI)
 Supine/left lateral decubitus position
 Palpate with fingers horizontally across chest at 4/5 th ICS
 Occupied 1 ICS, lateral displacement= cardiomegaly
2. Heaves
 Precordial impulse that can be palpated
 Place heel of hand parallel to left sternal border
 Positive- Heel lifted with systole = ventricular hypertrophy
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3. Thrills
 Palpable vibration caused by turbulent blood flow (palpable murmur)
 Flat of fingers and palms horizontally over 4 heart valves

Auscultation
 Auscultate upwards, starting with mitral
 Auscultate with diaphragm then bell

 Auscultate carotid artery with patient holding breath for radiation of aortic stenosis murmur
 Sit patient forward, auscultate aortic valve during expiration for aortic regurgitation
 Roll to left side listen to mitral valve with bell at expiration for mitral murmurs

Auscultate lung bases for crackle = pulmonary oedema 2 nd to left ventricular failure

Respiratory examination
Inspection
Age

Treatments/adjuncts around bed

Out of breath?

Scars

Cyanosis

Chest wall

Cough: productive(bronchiectasis/COPD/CF), dry (Asthma/ILD)

Wheezing: asthma/COPD/ bronchiectasis

Stridor: upper airway obstruction

Hands
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Skin examination
Inspect and palpate any growths Red – fever, blushing, inflammation
 Colour Blue – hypoxia, abnormal haemoglobin
 Moisture
 Temperature Yellow – jaundice (sclera yellow, carotenaemia (sclera not yellow)
 Textures Brown – increased melanin
 Mobility
 Turgor Pale – decreased melanin, decreased oxyhaem, oedema

Note any lesions and: Flat lesion: Macule < 1cm, Patch >1cm
 Anatomical location and distribution Raised/fluid filled: vesicle < 1cm, bullae >1cm
 Pattern and shapes
 Types Raised/non-fluid filled: papule < 1cm, Plaque >1cm
 Colour
Cancers: Squamous cell carcinoma, Basal cells carcinoma, Melanoma
Identifying early stages of melanoma: Asymmetry
i. Border irregularity
ii. Colour: blue/black, white & red
iii. Diameter: greater than 6mm
iv. Evolving: changing rapidly (most sensitive criteria)
v. Elevated
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vi. Firm
vii. Growing progressively over several weeks
Benign version = benign nevi- symmetrical, regular borders, even in colour

Hair
Inspect and palpate, note:
- Quantity
- Distribution
- Texture

Nails
Inspect and palpate fingernails & toenails, note:

o Colour
o Shape
o Any lesions