Makindo Medical Notes

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

Introduction

• Wash your hands thoroughly before starting the examination.
• Introduce yourself, confirm the patient’s name, date of birth, and explain the purpose of the examination.
• Obtain informed consent and ensure the patient is in a comfortable, private setting.

Equipment Needed

• Examination gloves
• Reflex hammer
• Cotton wisp or tissue (for light touch)
• Disposable pin or neurotip (for pinprick sensation)
• 128 Hz tuning fork (for vibration sense)

Background Information

Step 1: General Inspection

• Observe both lower limbs for symmetry, muscle bulk, and any involuntary movements or postural abnormalities.
• Note any skin changes such as scars, discoloration, or varicosities.
• If the patient is ambulatory, observe their gait for signs of limping, foot drop, or imbalance.

Step 2: Motor Examination

• Hip Examination:
  • Assess hip flexion, extension, abduction, and adduction by asking the patient to move against resistance.
  • Note any weakness, pain, or asymmetry.
• Knee Examination:
  • Test quadriceps strength by asking the patient to extend the knee against resistance.
  • Assess hamstring strength by testing knee flexion.
• Ankle and Foot Examination:
  • Evaluate ankle dorsiflexion and plantarflexion, as well as inversion and eversion, against resistance.
  • Assess toe movements and grip strength of the foot.

Step 3: Sensory Examination

• Light Touch:
  • Use a cotton wisp or tissue to test light touch sensation along the dermatomes (L1–S1) of the lower limb.
  • Compare both sides for any differences.
• Pinprick Sensation:
  • Use a disposable pin to assess sharp sensation over the same dermatomes.
• Proprioception and Vibration:
  • Test proprioception by moving the patient’s great toe up or down and asking them to identify the direction.
  • Place a 128 Hz tuning fork on a bony prominence (e.g., the big toe or ankle) to assess vibration sense.

Step 4: Reflex Examination

• Knee Jerk (Patellar Reflex):
  • Test the patellar tendon reflex (primarily L3–L4) by tapping the tendon while the patient’s leg is relaxed.
• Ankle Jerk (Achilles Reflex):
  • Test the Achilles tendon reflex (primarily S1) by striking the tendon while the foot is slightly dorsiflexed.
• Plantar Reflex:
  • Stroke the lateral aspect of the sole to assess the plantar response; note if it is flexor (normal) or extensor (Babinski sign, which is abnormal in adults).

Step 5: Coordination and Gait Assessment

• Heel-to-Shin Test:
  • Ask the patient to run the heel of one foot down the shin of the opposite leg.
  • Observe for smoothness and accuracy of the movement.
• Gait Assessment:
  • If the patient is able to walk, observe their gait for balance, stride length, and any abnormalities such as foot drop or a steppage gait.

Step 6: Closure

• Thank the patient for their cooperation and ensure they are comfortable before concluding the exam.
• 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 clearly.

Key Points for OSCE

• Adopt a systematic approach: Inspection → Motor Examination → Sensory Examination → Reflexes → Coordination and Gait.
• Explain each step to the patient to maintain comfort and cooperation.
• Compare findings bilaterally to detect any asymmetries or focal deficits.
• Accurately document all findings.

Common Pitfalls

• Failing to maintain patient privacy or adequately explain the procedure.
• Rushing through the examination and missing subtle deficits.
• Not comparing both sides thoroughly.
• Overlooking sensory testing in multiple dermatomes.

References & Further Reading

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