Upper and Lower Limb Neurology (OSCE)

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) |Upper and Lower Limb Neurology (OSCE)

👋 Introduction (WIPER)

• W – Wash hands.
• I – Introduce yourself + confirm details.
• P – Permission & explain exam.
• E – Expose upper & lower limbs, gather equipment (tuning fork, cotton wool, tendon hammer, pen torch).
• R – Position: lying at 45° or supine for motor/sensory testing.

1️⃣ Inspection

• Environment: mobility aids (stick, frame, wheelchair), splints, orthoses.
• Arms & legs:
  • Asymmetry, scars, deformities.
  • Muscle wasting, fasciculations (LMN signs).
  • Contractures, claw hand, wrist drop, foot drop.
  • Skin: trophic changes, ulcers (neuropathy), Charcot joints.
• Back & posture:
  • Spinal scars, kyphosis, scoliosis.
  • Abnormal movements: tremor, chorea, dystonia, dyskinesia.

2️⃣ Motor Examination 💪

• Screening: pronator drift (UMN sign).
• Tone: flexion/extension, pronation/supination, check for spasticity (UMN ↑ tone), flaccidity (LMN ↓ tone).
• Power (MRC scale 0–5):
  • Shoulder abduction (C5), adduction (C6–8).
  • Elbow flexion (C5/6), extension (C7).
  • Wrist flexion (C8), extension (C7).
  • Finger flexion/extension (C8, T1), abduction/adduction (T1).
  • Thumb opposition/abduction (C8/T1).
• Reflexes:
  • Biceps (C5/6) 💪
  • Supinator (C5/6)
  • Triceps (C7) 💥
  • Hoffman’s sign → UMN lesion.
• Coordination:
  • Finger–nose → past pointing, intention tremor (cerebellum).
  • Dysdiadochokinesis → cerebellar dysfunction.
  • Rebound phenomenon.

3️⃣ Sensory Examination ✋🦶

• Test on a normal area first (sternum/forehead) to calibrate.
• Dermatomes:
  • C5 – lateral upper arm
  • C6 – thumb 👍
  • C7 – middle finger ☝️
  • C8 – little finger
  • T1 – medial forearm
  • L4 – medial calf/knee
  • L5 – dorsum of foot, great toe
  • S1 – lateral foot/sole
• Modalities:
  • Light touch (cotton wool) → spinothalamic/dorsal column.
  • Pinprick (neurotip) → spinothalamic.
  • Temperature (cold/hot tubes).
  • Vibration sense (128 Hz tuning fork, distal → proximal).
  • Proprioception: up/down movement of great toe/fingers.
  • Two-point discrimination.
• Describe pattern: dermatomal, glove-and-stocking, hemisensory, sensory level.

4️⃣ Lower Limb Motor 🦵

• Power:
  • Hip flexion (L1–3), extension (L5/S1).
  • Knee extension (L3/4), flexion (L5/S1).
  • Ankle dorsiflexion (L4/5), plantarflexion (S1/2).
  • Big toe extension (L5).
• Reflexes:
  • Knee jerk (L3/4) 🦵
  • Ankle jerk (S1) 👣
  • Plantar response → Babinski sign (UMN = upgoing).
• Coordination:
  • Heel–shin test (cerebellum).

5️⃣ Gait 🚶

• Normal walking → base, arm swing, posture.
• Heel walking (L4/5 weakness).
• Toe walking (S1 weakness).
• Tandem walking (cerebellar ataxia).
• Look for Parkinsonian, hemiplegic, spastic, high-stepping (foot drop), waddling (proximal myopathy) gait.

📊 Classic Patterns

• UMN: spasticity, hyperreflexia, clonus, upgoing plantars.
• LMN: wasting, fasciculations, flaccid tone, hyporeflexia, downgoing plantars.
• Cerebellar: ataxia, intention tremor, dysdiadochokinesis, nystagmus, scanning speech.
• Peripheral neuropathy: glove-and-stocking loss, reduced reflexes, wasting.

🙏 Closure

• Thank patient, redress, wash hands.
• Present findings systematically: “This patient has UMN signs in the right upper limb, consistent with …”
• Suggest further exams: cranial nerves, fundoscopy, full cognitive exam, neuroimaging, NCS/EMG, blood tests (B12, glucose, thyroid).

💡 OSCE Pearls

• Always test normal area first for sensation. • Kneel at eye level when testing lower limbs. • Don’t forget reflex reinforcement if absent. • Say you’d test cranial nerves + cerebellum to complete neuro exam. • Compare both sides carefully and describe distribution.