Makindo Medical Notes

Related Subjects: |Breast Anatomy and Examination (OSCE) |Shoulder examination(OSCE) |Testicular examination(OSCE) |Hernia Examination (OSCE) |Rectal examination (OSCE) |Liver Examination (OSCE) |Cerebellar Examination (OSCE)

Introduction

• Hand Hygiene: Wash your hands thoroughly before beginning the exam.
• Patient Introduction: Introduce yourself, verify the patient’s name and date of birth, and explain that you will be assessing their cerebellar function.
• Consent & Comfort: Obtain informed consent and ensure the patient is in a quiet, well-lit room with sufficient space, proper exposure, and privacy.

Equipment Needed

• Examination gloves
• Optional: Pen and paper (for drawing tasks or documentation)
• No special equipment is required for most cerebellar tests.

Background

Step 1: General Observation

• Observe the patient’s overall posture, gait, and any signs of ataxia or unsteadiness.
• Note visible tremors, head titubation (rhythmic nodding), or irregular movements that may indicate cerebellar dysfunction.

Step 2: Cranial and Ocular Examination

• Eye Movements & Nystagmus:
  • Ask the patient to look straight ahead, then follow your moving finger in an “H” pattern.
  • Observe for nystagmus – note its direction, speed (fast phase), and whether it is gaze-evoked or present at primary gaze.
  • Differentiate normal physiological nystagmus (at extreme gaze) from pathological nystagmus seen with cerebellar lesions.
• Scanning Speech:
  • Ask the patient to read a standard phrase (e.g., “British Constitution”) or repeat a short sentence.
  • Listen for scanning speech – characterized by breaks between syllables, irregular rhythm, and unusual stress patterns.
  • This type of ataxic dysarthria is a key sign of cerebellar dysfunction.

Step 3: Upper Limb Coordination and Motor Tests

• Finger-to-Nose Test:
  • Ask the patient to extend one arm fully, then touch the tip of their nose and then your outstretched finger.
  • Observe for dysmetria (overshooting/undershooting) and intention tremor, which becomes more pronounced as the target is approached.
• Rapid Alternating Movements:
  • Instruct the patient to rapidly alternate between pronation and supination of the hands.
  • Assess for dysdiadochokinesia – irregular, slow, or clumsy movements indicate cerebellar impairment.
• Rebound Phenomenon & Pronator Drift:
  • Ask the patient to hold their arms out straight (palms up) and close their eyes.
  • Gently push down on the forearms and then suddenly release. An absent or exaggerated rebound (overshooting) suggests impaired coordination.
  • Observe for any pronator drift, which may also indicate cerebellar or upper motor neuron involvement.

Step 4: Lower Limb Coordination and Gait

• Heel-to-Shin Test:
  • Have the patient either lie down or sit with legs extended.
  • Instruct them to run the heel of one foot down the opposite shin smoothly, then repeat on the other side.
  • Assess for dysmetria – irregular, zigzag movements suggest cerebellar dysfunction.
• Gait and Balance Assessment:
  • Tandem Gait: Ask the patient to walk in a straight line, placing one foot directly in front of the other. Observe for imbalance or a wide-based gait.
  • Romberg Test: With the patient standing, ask them to close their eyes. Note any increased swaying. (Remember: a positive Romberg indicates sensory ataxia rather than cerebellar ataxia.)

Step 5: Additional Cerebellar Signs

• Observation for Intention Tremor:
  • During the finger-to-nose test, note if the tremor intensifies as the patient’s finger nears the target.
• Assessment of Hypotonia:
  • Gently assess muscle tone in the limbs by passively moving them; note any reduced resistance, which can be associated with cerebellar lesions.

Step 6: Closure

• Thank the patient for their cooperation and ensure they are comfortable.
• Provide a concise summary of your findings and explain any further investigations or referrals if necessary.
• Wash your hands again and document your examination findings clearly.

Key Points for OSCE

• Maintain a systematic approach: Start with general observation, then cranial/ocular exam, followed by limb coordination and gait assessment.
• Clearly explain each step to reduce patient anxiety and ensure cooperation.
• Specifically assess for scanning (staccato) speech and abnormal eye movements (nystagmus), which are hallmark signs of cerebellar pathology.
• Compare bilateral findings for subtle asymmetries.

Common Pitfalls

• Failing to use adequate lighting, leading to missed subtle eye or skin changes.
• Rushing through the examination and overlooking key signs such as scanning speech and nystagmus.
• Not explaining maneuvers properly, which may cause patient apprehension.
• Confusing a positive Romberg (sensory ataxia) with cerebellar ataxia.

References & Further Reading

• Stanford Medicine 25: Cerebellar Examination – A comprehensive guide to cerebellar signs.
• Geeky Medics OSCE Resources
• Wikipedia: Scanning Speech
• StatPearls: Cerebellar Neurological Signs – Detailed descriptions of cerebellar signs and their clinical significance.