This is divided this in to upper
and lower limbs, and we
suggest that you separate the examination in this order: it may be uncomfortable for the patient to have all his
limbs exposed at the same time, it is also makes it easier to remember. The commonest OSCE station is an upper/lower motor neuron
lesion, and you should keep this in mind when examining.
Tendon hammer (the bigger the better, within reason)
Say "may I examine your arms," and expose the patient's
Observe for fasciculation, wasting (both can be very
Protonator drift: ask the patient to close their eyes with
straight out and their palms up, observe to see if arms protonate in.
"let your arms go floppy and let me take them, don't help me when I do
this." Take their hand with your hand (as if to shake it), and flex and
extend the patient's arm, supinate and protonate, and rotate their
Over the biceps (C5), supinator (C6), and triceps (C7)
groups. Hold the
tendon hammer like a hammer loosely at its end. Palpate the tendon to
be hit, and rather than strike the it let it drop down loosely. Use
reinforcement techniques (jaw clenching) if absent.
Finger-nose test: you need to hold your finger far enough
away for the patient to have to stretch their hand to touch yours
the easiest way is to get the patient to put their hand palm down on
their lap, then turn it over and repeat as fast as they can.
Get the patient to hold their arms out in the anatomical
rested on the bed (i.e. palms up, arms and fingers extended).
For pin-prick, temperature and light touch test
in all the
, comparing sides. Say "can you close your eyes,
tell me when I touch you... Does it feel the same on both sides." For
light-touch use cotton wool, temperature the base of a tuning fork, and
pin-prick a neuro-tip. Neuro-tips are not painful exactly just sharp,
so say "does this feel sharp?"
For vibration and proprioception it is
sufficient to test distally and only move proximally if absent.
Vibration is tested with a tuning fork. Proprioception is tested by
getting the patient to close their eyes, holding the distal phalanx of
a finger and moving it
up and down,
getting the patient to name the movement.
Say "may I examine your legs," and expose the patient's
Observe for fasciculation, wasting
Say "I'm going to roll your legs, let your legs go
floppy." Roll the
legs and observe to see if the foot follows immediately (increased
tone) or if it lags a bit (normal). Say "I'm going to lift your leg
Pull vertically up at the knee and
observe if the foot comes off the bed (increased tone, or the patient
The important muscle groups to test are:
Hip flexion - L1, L2
Hip ext - L5, S1
Knee ext - L3, L4
Knee flexion - L5, S1
Dorisiflexion - L5
Plantarflexion - S1
Ankle jerk (S1, S2), Knee jerk (L3, L4). The knee jerk is
easy to elicit. Put your arm under their knee and say "let your leg go
floppy, and let me take the weight." The leg should feel heavy on your
arm. Palpate and hit the tendon with the hammer. The ankle jerk is
harder to elicit (and often absent in the elderly). Bend the patients
leg, and with your non-dominant hand hold the curve of their feet and
slightly flex it, then hit the ankle tendon.
Get the patient to lift up their leg, put their ankle on
draw it down the leg, adn repeat the procedure as fast as they can.
The modalities should be tested the same as in the arms.
Gait should be tested if practical
Romberg's test should be performed if the patient has
problems. Get the patient to stand up and ask them if they would be
unsteady if they closed their eyes. If they say no, then stand close to
them at right angles, and put one hand in front and one hand behind,
and ask them to close their eyes. It does not look good if you haven't
prepared to catch them and they fall over!
Common OSCE stations
Upper motor neuron disease:
motor neuron disease