© 2013 Dr Christopher Mansbridge at www.oscestop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

Focussed questions What happened when you first presented with this condition? How is it affecting you? When is your tremor worst? Do you have other problems, such as problems with balance or co-ordination? Do you have problems with buttons and shoe laces? Turning over in bed at night? Getting in and out of your car?

Examining for tremor 1. Resting (rest hands on lap and close eyes and countdown from 20) e.g. parkinsons 2. Postural tremor (hold arms out) e.g. benign essential tremor; drugs (salbutamol), hyperthyroid 3. Action tremor (finger nose test) e.g. cerebellar

Parkinson’s Disease Focussed Examination

NB. the instructions may be non-specific e.g. Examine this patient with a tremor (may be Parkinson’s or cerebellar) or examine this patient neurologically. In this case, approach by asking a few focussed questions and finding out which type of tremor/condition is present and then proceed with the relevant examination to elicit all the signs of the condition.

Introduction

Wash hands, Introduce self, ask Patients name & DOB & what they like to becalled, Explain examination and get consent

General Observations General

Walking aids etcTremor

Note if obviously visible tremor (if not, get patient to close their eyes and count down from 20 to distract them)o asymmetrical resting pill rolling tremor (4 - 8 Hz)o begins distally (fingers, hands, forearm), can involve chin and moutho reduced with finger to nose testingo tremor can be accentuated by patient clenching contralateral hand or counting serial 7's

Gait and Posture

Get them to walk up and down roomo shuffling gait (reduced stride length precedes)o hesitant: difficulty initiating and turning (multiple steps)o festinating gait: patient walks faster and faster as to not fall overo lack of arm swing (early sign due to increased tone)o Unsteadiness (propulsion/retropulsion - tendency to fall forward or backwards)

Observe posture while walkingo stooped posture

NOW…work down the body

Face Face

Observe faceo “hypomimia” (mask like face): blank and expressionless face with decreased blinkingo Drooling

Eyes

Glabella tap (Myerson’s sign= blinking fails to cease with continued tapping)

Vertical eye movements (Progressive supranuclear palsy = vertical limitation, loss of down gaze first)

Speech

Say a sentence about themselves and what they’ve done today OR describe the room they are in o hypophonia (quiet)o soft, faint and hard to understando slow thinking

Focussed Upper Limbs

Tone (You can augment increased tone be getting patient to distract themself by moving contralateral arm up and down)o led pipe= increased tone; cogwheel rigidity = tremor superimposed on increased tone

Bradykinesiao open and close thumb and index finger like snapper as fast as possible (lack of amplitude and slow and not in sync)o play imaginary piano (slow)o open and close big imaginary doorknob (difficulty pronating and supinating)

Focussed Lower Limbs

Bradykinesia (foot stamping)

© 2013 Dr Christopher Mansbridge at www.oscestop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

o lack (or decay) of amplitude and slow and not in sync. “cadence” = disordered

Function

See writing (micrographia)

Undo buttons

To complete

Posture blood pressure (low in PD with autonomic neuropathy)

Mini-mental state (PD with dementia)

See drug chart (parkinsonism drugs)

Parkinsons plus syndromes: o Progressive supranuclear palsy: eye movements (vertical limitation, loss of down gaze first); axial rigidity by shaking

shoulders (in PSP axial>peripheral) o Multisystem atrophy: cerebellar exam (e.g. nystagmus); postural hypotension (autonomic problems) o Corticobulbar degeneration: neuro exam

Summarise and suggest further investigations you would do after a full history

Degeneration of the dopaminergic neurons in the substantia nigra. Lewy bodies present. CAUSES= idiopathic, parkinsonism (e.g. drugs), supranuclear palsy, Wilsons, multi-system atrophy, cerebrovascular Less likely to be idiopathic if don’t respond to Ldopa; bilateral signs; hyperreflexic; up plantars SIGNS= rigidity, bradykinesia, asymmetric resting tremor, postural instability