Makindo Medical Notes

Related Subjects: |OSCE Eye Exam |OSCE Ear Exam |OSCE Abdominal Exam |OSCE Testicular Exam |OSCE Inguinal Exam |OSCE Upper limb Neurology

Introduction

• Wash your hands thoroughly before beginning the examination.
• Introduce yourself and confirm the patient’s name, date of birth, and reason for the assessment.
• Explain the purpose of the examination and obtain informed consent.
• Ensure the patient is comfortable in a quiet, well-lit room with appropriate privacy and draping.

Equipment Needed

• Examination gloves
• A reflex hammer
• A cotton ball or a piece of tissue (for light touch)
• A disposable pin or neurotip (for pinprick sensation)
• A 128 Hz tuning fork (for vibration sense)
• Optional: Pen and paper for fine motor tasks

Useful Clinical Notes

Step 1: General Inspection

• Inspect both upper limbs for symmetry, muscle bulk, and any involuntary movements (such as tremor or fasciculations).
• Note any skin changes (scars, rashes, pigmentation) or signs of muscle atrophy.

Step 2: Motor Examination

• Power Assessment:
  • Test major muscle groups of the shoulder, elbow, wrist, and hand using the Medical Research Council (MRC) scale (0 to 5).
  • Ask the patient to perform movements such as shoulder abduction, elbow flexion/extension, wrist flexion/extension, and hand grip.
• Tone Assessment:
  • Palpate muscles to assess tone; note any increase (spasticity) or decrease (flaccidity) in tone.

Step 3: Sensory Examination

• Light Touch:
  • Use a cotton ball to gently test light touch sensation over the dermatomes (C5 to T1) of the upper limb.
  • Compare both sides for any asymmetry.
• Pinprick Sensation:
  • Use a disposable pin or neurotip to assess sharp sensation in the same regions.
• Proprioception and Vibration:
  • Test proprioception by moving the patient’s fingers (or thumb) up or down and asking them to identify the direction.
  • Place a 128 Hz tuning fork on bony prominences (e.g., wrist or elbow) to assess vibration sense.

Step 4: Reflex Examination

• Test deep tendon reflexes and compare bilaterally:
  • Biceps Reflex: (C5/C6)
  • Brachioradialis Reflex: (C6/C7)
  • Triceps Reflex: (C7/C8)
• Note any hyperreflexia, hyporeflexia, or asymmetry between sides.

Step 5: Coordination and Fine Motor Skills

• Finger-to-Nose Test:
  • Ask the patient to alternately touch their nose with their index finger.
  • Observe for dysmetria (overshooting or undershooting) and tremor.
• Rapid Alternating Movements:
  • Instruct the patient to rapidly alternate between pronation and supination of the hands.
  • Look for signs of dysdiadochokinesia.
• Fine Motor Tasks:
  • If appropriate, ask the patient to perform tasks such as finger tapping or drawing a simple spiral to assess dexterity.

Step 6: Special Tests (If Indicated)

• Tinel’s Sign:
  • Gently tap over the course of the median nerve at the wrist to check for tingling (suggestive of carpal tunnel syndrome).
• Phalen’s Test:
  • Ask the patient to flex their wrists and hold the position for 60 seconds; note any paresthesia in the median nerve distribution.

Step 7: Closure

• Thank the patient for their cooperation.
• Provide a brief summary of your findings and explain any further investigations or management plans if required.
• Wash your hands again and document your examination findings accurately.

Key Points for OSCE

• Adopt a systematic approach: Inspection → Motor Examination → Sensory Examination → Reflexes → Coordination.
• Explain each step clearly to reduce patient anxiety and ensure cooperation.
• Compare findings bilaterally to detect any asymmetry or focal deficits.
• Ensure accurate documentation of all findings.

Common Pitfalls

• Failing to explain the examination process, leading to patient discomfort.
• Missing subtle sensory deficits by not testing in multiple dermatomal areas.
• Not comparing both sides for strength and reflex differences.
• Rushing the examination without a systematic approach.

References & Further Reading

• Clinical Examination: A Systematic Guide to Physical Diagnosis by Talley & O'Connor.
• Geeky Medics OSCE Resources
• OSCEstop – Online OSCE practice resources.